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Li-FT® MEDICAL HEALTH FORM
First Name
Last Name
Address
Phone
Date of birth
Email
Are you pregnant or nursing?
Yes
No
Have you had any alcohol in the last 24 hours?
Yes
No
Have you ever had cold sores or fever blisters?
Yes
No
Do you have any allergies to latex?
Yes
No
Have you had a laser or chemical peel within 6 months?
Yes
No
Have you ever had any permanent cosmetics or tattoos applied?
Yes
No
Do you bruise easily for no obvious reason?
Yes
No
Do you routinely use Retin-A, glycolic, or other exfoliating products?
Yes
No
Do you wear contact lenses?
Yes
No
Are you allergic or sensitive to any metals, for instance metals used for jewelry?
Yes
No
Do you have any problems healing?
Yes
No
Is your skin oily?
Yes
No
Do you use tobacco? If you use tobacco you may heal slower and this affects the timing on scheduling a touchup appointment, if applicable.
Yes
No
Do you have any heart conditions?
Yes
No
Are you diabetic? If so, Type 1 or Type 2?
Yes
No
Do you have any autoimmune disorders?
Yes
No
Are you sensitive or allergic to hand creams or body lotions?
Yes
No
Do you have your lips injected with filler materials?
Yes
No
Do you have botox injections?
Yes
No
Do you hyper-pigment? (Tendency to develop dark spots on the skin from wounds or sun)?
Yes
No
Do you tend to develop keloid or hypertrophy scars?
Yes
No
Do you tend to develop keloid or hypertrophy scars?
Yes
No
Do you have any seizure related conditions?
Yes
No
Do you tend to faint or become dizzy?
Yes
No
Do you bleed excessively from minor cuts?
Yes
No
Do you have prosthetic implants?
Yes
No
Do you have prosthetic implants?
Yes
No
Do you consume aspirin daily?
Yes
No
Are you under treatment for depression?
Yes
No
Do you have any type of herpes?
Yes
No
Are you sensitive to petroleum-based products?
Yes
No
If you have permanent cosmetics or tattoos, did you have any problems with healing after they were applied?
Yes
No
Are you undergoing radiation or chemo-therapy treatment?
Yes
No
Are you now, or have you ever
Yes
No
Are you wearing a pacemaker?
Yes
No
Do you take prescription drugs?
Yes
No
Are you anemic?
Yes
No
Do you have a history of skin sensitivities?
Yes
No
Do you have any medical condition that has resulted in a medical professional requiring you to pre-medicate with an antibiotic prior to a dental or other invasive procedure?
Yes
No
Do you have allergies to makeup?
Yes
No
Do you have dry eyes?
Yes
No
Do you intentionally tan – Direct sun or tanning bed?
Yes
No
Do you personally have any history of cancer?
Yes
No
Do you have a history of stroke or heart attack?
Yes
No
To your knowledge are you allergic or resistant to over the counter level numbing products such as ELA-Max?
Yes
No
Are you allergic to hair dyes?
Yes
No
Do you have glaucoma or any other eye disease?
Yes
No
Do you have arthritis?
Yes
No
Do you have high or low blood pressure?
Yes
No
Do you have sinus problems?
Yes
No
Have you experienced Hepatitis or Jaundice during the past 12 months?
Yes
No
If you answered “Yes” to any questions above, use the this box to provide an explanation.
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