CLIENT HISTORY (Please print and fill out this form. Bring it with you on your initial visit to ABOUT FACES!)     Name___________________________________________________________ Date of Birth ____________ Address ________________________________________________________________________________ Street ~ City ~ State ~ Zip Home Phone _______________________________ Business Phone _____________________________ May we contact you at these numbers? ___________________ Referred by _____________________________________________________________________________ Emergency Contact __________________________________________ Phone Number _________________ Driver’s License # __________________________________________ Social Security # ________________   PROCEDURE(S) DESIRED: _________ Upper eyeliner __________ Partial eyebrows __________ Lipliner __________Beauty Mark _________ Lower eyeliner __________ Full eyebrows __________ Full lip color __________Scar Camouflage _________ Other: ________________________________________________________________________   ALLERGIES: Check if you have ever had an allergic reaction to any of the following & describe what happened below: ________Lanolin _______ Latex rubber _________ Bacitracin Ointment _________ Novocaine ________Neomycin or polymyxin B ointment ________ Lidocaine _________PABA ________Foods:__________________________________________________________________________ Other allergies: ___________________________________________________________________________ Reaction: _______________________________________________________________________________   EYES/EYEBROWS: Check all of the following that apply: _______ Contact Lenses ________ Eye makeup sensitivities __________ Dry eyes ________Blurred Vision _______Thyroid abnormalities ________ Glaucoma _________ Alopecia Universalis (total) _______ Alopecia Areato (local) ________ Other hair loss, describe: ____________________________ _______ Pull out lashes or eyebrows compulsively (Trichotillomania) _______Eyebrow tinting, date of last service: ____________________ Other eye disorders: _______________     LIPS: Check all of the following that apply: _______ Cold sores/fever blisters/herpes around the mouth.   If yes, a prescription for Zovirax is required prior to any lip procedure. _______ Collagen injections - location: _______________________ _______ Fat transfer injections - location: _____________________ _______ Gore-Tex implants - location: _______________________   SKIN: Check all of the following that apply: _______ Any other tattoos - location _________________Age of tattoo: ________ any problems _______ _______ Use of sunlamp/tanning bed/ suntan outdoors _______ Are you currently tan in the area to be treated? _______ Currently use Retin-A - location ___________________________________________________ _______ Currently using glycolic acid or other AHA skin products ________________________________ _______ Have you ever had a chemical peel?When ______________ What type of peel _______________ _______ Do you have a scar you want camouflaged? Age of scar: ________________________________ _______ Any keloid or hypertrophic scars - location: __________________________________________ _______ Bruise of bleed easily __________ Healing problems _______ Other active dermatological disorders: Describe:_______________________________________   GENERAL MEDICAL: Check all of the following that apply: _______ High Blood Pressure _________ Diabetes _________ Hemophilia or other clotting disorders _______ Currently on blood thinners of anticoagulants such as Aspirin, Ibuprofin, Coumadin, Alcohol _______ Mitral valve prolapse or valve implants _________ Heart Palpitations _______Taken Accutane within the last 6 mos. _______ Pregnant or nursing _______ Ever had Hepatitis -When?___________________________ _______ Autoimmune disorders _______ Seizures - Describe_________________________________ Please list surgeries:____________________________________________________________________ If you are planning cosmetic or other surgery in the near future, describe:____________________________ List all medications, prescription and non-prescription, that you have taken in the last two weeks: __________________________________________________________________________________ If you are currently under a physician’s care for any condition, describe: ____________________________ Physician’s name: _________________ City: ___________________ Phone number _______________   This history has been reviewed by the technician and my questions have been satisfactorily answered. I have also received and reviewed a copy of the Pre-Procedure Information Sheet and the After Care Sheet. I understand them and agree to follow them.   Signature__________________________________ Date: _______________             Copyright, Society of Permanent Cosmetic Professionals 9/95