Laser Department Checklist
History
Any lotion,oil,cream or powder
Yes
No
Diet(red,wine,spicy food)
Yes
No
Medication
Yes
No
Pregnancy
Yes
No
Sun exposure(tanning)
Yes
No
Keloids
Yes
No
Hernia
Yes
No
Anticoagulant Medication
Yes
No
Open Wounds
Yes
No
Botox
Yes
No
Filters
Yes
No
Birthmarks
Yes
No
Metal Inplant
Yes
No
Tattoo
Yes
No
Mole
Yes
No
Chemical Peel
Yes
No
Eczema
Yes
No
Psoriasis
Yes
No
Vitiligo
Yes
No
Allergy
Yes
No
Occasion(Wedding/Party,Travel,Meetings)
Yes
No
Previous Laser Treatment
Burn
Yes
No
Discoloration/Pigmentation
Yes
No
Itchiness
Yes
No
Increase of hair growth
Yes
No
Pimples
Yes
No
Redness
Yes
No
Swelling
Yes
No
Patient Signature
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Clear