LymphWorks, LLC
2023 Skin Health History Intake & Agreements
Required Field
Personal Info
First Name
Last Name
Date of Birth (MM/DD/YYYY)
Gender
M
F
Identify as
Identify as
Occupation
Contact Info
Mobile Phone
Email
Source of Referral
Skin History / Current Skin Related Issues
Skin
Acne
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0
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Psoriasis
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Allergic Dermatosis
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Herpes/ Cold Sores
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0
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Rosacea
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Hypersensitive Reactions
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Skin Cancers
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Skin Conditions
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Infectious Skin Conditions
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Melasma / Pigmentary Disorder / Hyper or Hypopigmentation
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Chemical Peels? Last one when?
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Botox Treatment? When and where?
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Combination Skin?
Dry Skin
Oily Skin?
Eczema / Dermatitis (where)
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Cosmetic Surgery / Procedure (where and when)?
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Plasma Pen Treatment (Fibroblast) (where and when?)
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Laser Resurfacing (where and when)?
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Injectable Fillers (If so, where and when?)
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Tattoo / Permanent MakeUp (where?)
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Cancerous lesions or suspected cancer? Where?
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Latex sensitivity/ Allergy
Keloid Scars / Excessive Scarring
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Problems with Healing?
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Other
Wearing Contact Lenses (please take off if we are treating eyelids)
Implanted neurostimulator or electrical implanted device, or implanted slow medication release?
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Pregnant / Nursing?
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Pacemaker or electrical implant (Where)?
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Thyroid Disease?
HIV / Aids?
High Blood Pressure
Iron Deficiency / Anemia
Epilepsy- Seizures
Hypoglycemia
Diabetes
Surgeries
Surgery
Add Another Surgery
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