RENEW MEDISPA : REDEFINE THE WAY YOU AGE

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Our Services

	Botox
	Hyaluronic Fillers
	Radiesse Dermal Filler
	Laser Hair Removal
	IPL Photofacial
	Vein Treatment
	Laser Skin Resurfacing
	Medical Microdermabrasion
	Rx Chemical Peels
	The Obagi Blue Peel
	Latisse Eyelash Enhancement
	Mineral Makeup Application and Instruction

Medical History Form

Renew MedSpa Medical History Form .*note you will be able to email this form when you finish it.

*Name		*Home Number
Address		How do you hear about Us?
Cell Number		Sex
City		State
*Email		DOB
Profession		Emergency Contact

General

Allergies (Food, Latex, or other	Asthma/Difficulty breathing	Skin or Nail Infections
HIV / AIDS (you may discuss privately)	Aroma /Inhalant Sensitivity	Cold Sores/Shingles/Herpes
Cancer (please tell clinician	Chronic Fatigue or Pain	Addictive disorders
Anxiety or Depression	Sleep disturbances	Connective Tissue disorders
Smoker (please tell clinician)	Alcohol/Drugs (Type)	Special Diet or Nutritional Needs
	Other (please tell clinician)

Endocrine System Urinary System Neurological System

Thyroid or other gland disorder	Kidney Disease/Infections	Headaches
Diabetes/Type		Seizures
Steroid, or Hormone Therapy		Orientation/Memory Disorders
Melasma/ Mask of Pregnancy		Limb, body weakness
		Numbness/Tingling/Sensory loss

Musculoskeletal System CardioVascular System Gastrointestinal System

Joint Pain/Stiffness/Swelling	Heart Disease	Colitis/IBS/Food intolerance
Fibromyositis/Myalgia	High/Low Blood Pressure	Stomach Ulcers/Reflux
Neck Pain	Dizziness/Fainting	Liver Disorders
Low Back Pain	Bruise Easily	Gallbladder Disorders
Extremity/Foot/Joint Pain		Constipation

Dermatological System

Unusual or cystic acne	Eczema, Psoriasis or Rashes	Keloid or Thick Scars
Skin discoloration	Burns or grafted skin	Skin Cancer (please tell clinician)
Birthmarks	Skin discoloration	Skin Reactions to treatments

Female Patients Male Patients Allergies (please list)

Pregnant/Breast Feeding	Testosterone Supplements
Menopause	Anabolic/Muscle enhancers	T
Abnormal Menses	Prostate disorders	T

Previous Treatments

Dermatological Surgeries	Cosmetic/Laser Peels	Body Contouring
Acutane/Retin-A/Renova \When _______Strength__________	Dermabrasion	Permanent Make-up
Plastic Surgery

Fitzpatrick Skin Typing: Please select the description that best explains the way your skin responds to the sun after 15minutes of unprotected exposure:

	Always burns, never tans (Type One)		Always burns, uneven tan & freckles (Type Two)		Sometimes burns, always tans, medium skin (Type Three)
	Rarely burns, always tans (Type Four)		Never burns, deeper tan - Hispanic or Asian (Type Five)		Never burns, increased tan - African American (Type Six)

Ethnic heritage		Natural Hair Color
Date of last use of self-tanner		Areas of body used
Date of recent sun tanning (15 minutes or more of continual exposure) or tanning beds
Please list any medications or herbal supplements you are taking at this time also include over the counter(include Aspirin)

Supplement currently using:

Calcium	Vitamin D	Fish Oil
St.John's Work	Glucosamine	Vitamin B
General MVI	Iron	Acai
Lactobacillus/Digestive Enzyme	Antioxidants
Others

Check the following treatments that you are interested in either today or at a later date or would like to know more about

Laser Facial	Laser Hair Removal	Peels
Fillers/Botox	Microdermabrasion	Personal Training
IPL Photofacials	Make-up	Weight Mgmt
Vein Removal

Check the following conditions that you would like to correct

Excess weight	Spots/Sunspots	Aging
Irritated/Sensitive Skin	Dryness	Acne
Rosacea	Melasma	Enlarged Pores
Wrinkles	Rough Skin Texture
Others

Do you consider yourself to be?

	High stress		Low stress		Medium Stress
	Any specifics?

By signing below, I acknowledge that the information disclosed in this health history form is accurate and complete and I have revealed all information to the best of my knowledge. I understand that this information will be kept confidential, viewed only by the Medical Director and any Renew MediSpa, LLC personnel that may be administering or assisting with my care. I further understand that any changes in my health history should be re-documented and updated by me immediately. I will advise Renew MediSpa , LLC of any changes in my health ormedical condition immediately. I will follow all pre and post care instructions for my treatments.

*Signature

*Date/Time Field

Photograph Consent and Release Form: I, the undersigned, do hereby agree to the following. I am allowing Renew MediSpa, LLc and Renew MediSpa , LLC staffmembers to take photos of my treatment and/or treated areas to be used for the purpose of monitoring my progress and clinical chart documentation,education and/or advertising. At my request, my identity will remain anonymous______________________________________________________________ (please initial).

	Signature		Date/Time Field
	Consultant / Witness

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