Patient Intake Form - Empower Med Spa

53 Fairfax Road, St Albans, VT 05478 802-528-2738

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Patient Intake Form

Please fill out the form below

Fields marked with an asterisk are required.

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Date*
Date Format: MM slash DD slash YYYY
Patient Name*
First Last
Address*
Street Address Address Line 2 City State ZIP
Email*
Phone*
May we leave a message?*
- Yes
- No
Preferred method of communication from our office? (please check all that apply)*
- Text
- Phone Call
- Email
Date of Birth*
Date Format: MM slash DD slash YYYY
Age*
Sex*
- Male
- Female
Marital Status
Occupation
Employer
Emergency Contact Name
Relationship
Emergency Phone
How did you hear about us?
Reason for consultation
Please describe your skin and skin concerns (please check all that apply)
- Thick
- Thin
- Saggy
- Firm
- Fine Lines
- Wrinkled
- Aging
- Dry
- Normal
- Oily
- Combination
- Large Pores
- Sun Freckles
- Uneven/Blotchy
- Active Acne
- Acne Scars/Scars
- Blackheads/Whiteheads
- Cysts
- Dark Spots/Patches
- Scaling/Flaking
- Broken Capillaries
- Sallow
- Puffiness
- Rosacea
- Dehydrated
- Eczema or Psoriasis
- Dark Circles/Eyes
Other
Are there any other treatments/conditions you are interested in hearing more about? (please check all that apply)
- Longer lashes
- Dark spots/hyperpigmentation
- Excessive sweating
- Thinning hair
- Vaginal rejuvenation
- Scar treatment
- Double chin
- Fine lines and wrinkles
- Skin laxity
- Medical grade skin care
- Acne
- Hair removal
Other
What is important to you when deciding on a skin treatment?

SKIN CARE
Do you have any special skin problems pertaining to your face and body?
- Yes
- No
If yes please specify
Do you experience irritation from shaving?
- Yes
- No
Do you experience ingrown hairs?
- Yes
- No
For unwanted hair do you
- Wax
- Tweeze
- Electrolysis
Describe your current skin care regimen:
What brand name(s) to do you use?
What spf sunscreen do you use on your face?
What spf sunscreen do you use on your body?
Please specify if you have had any recent sun exposure in the past 4-6 weeks, including tanning beds, bronzing creams or spray tans?
Are you using Retin-A, Hydroquinone (bleaching cream), glycolic acid, Accutane or any other medication that could cause sun sensitivity?
- Yes
- No
If yes please explain

SOCIAL HISTORY
Do you follow a restricted diet?
- Yes
- No
If yes please explain
Do you smoke cigarettes?
- Yes
- No
If so how many packs a day, how many years?
Do you drink alcohol?
- Yes
- No
If so how many drinks per day/week
Do you use drugs?
- Yes
- No
If yes please explain
Do you have regular sleep patterns?
- Yes
- No
If no please explain
Do you consume caffeinated products?
- Yes
- No
If yes please explain

MEDICAL HISTORY
Please fill out as completely as you are able. All information will be held in strict confidence.
Name of Primary Care Provider
Office Phone
Illnesses over past 5 years
Chronic or Current Conditions
Neurologic Conditions
- Yes
- No
If yes, please explain
Cardiovascular Conditions
- Yes
- No
If yes, please explain
Respiratory Conditions
- Yes
- No
If yes, please explain
Endocrine Conditions
- Yes
- No
If yes, please explain
Liver Conditions
- Yes
- No
If yes, please explain
Kidney Conditions
- Yes
- No
If yes, please explain
Autoimmune Conditions
- Yes
- No
If yes, please explain
Infectious Conditions
- Yes
- No
If yes, please explain
Coagulation Conditions
- Yes
- No
If yes, please explain
Hereditary Conditions
- Yes
- No
If yes, please explain
Connective Tissue Disorders
- Yes
- No
If yes, please explain
Cancers
- Yes
- No
If yes, please explain
Eye Conditions
- Yes
- No
If yes, please explain
Skin Conditions
- Yes
- No
If yes, please explain
Psychological Conditions
- Yes
- No
If yes, please explain
Surgery, Including Cosmetic
- Yes
- No
If yes, please explain
Do you faint easily?
- Yes
- No
Do you scar easily?
- Yes
- No
Do you have any allergies?
- Yes
- No
If yes, please explain
Drug Therapy
Please list any prescribed or over the counter oral or topical medications you are currently using, including: allergy medications, acne treatments, Aspirin, Ibuprofen, herbs & vitamins:
Pharmacy Name
Pharmacy Phone
Have you ever seen a dermatologist?
- Yes
- No
If yes, please explain
Dermatologist Name
Dermatologist Phone
SKIN CARE - have you ever had a chemical peel?
- Yes
- No
Last treatment date and area treated
SKIN CARE - have you ever had microdermabrasion?
- Yes
- No
Last treatment date and area treated
Have you ever had any laser or photofacial treatments in the past?
- Yes
- No
Last treatment date and area treated
Do you have hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin), keloid scars or marks/scars from physical trauma, chicken pox or acne?
- Yes
- No
If yes, please describe
Do you have any permanent cosmetic tattoos?
- Yes
- No
Last treatment date and area treated
Have you ever had Botox® or Dysport® injections?
- Yes
- No
Last treatment date and area treated
Have you had previous dermal filler, Kybella™or Sculptra® injections?
- Yes
- No
Last treatment date and area treated
Frequent or occasional cold sores to mouth or genitalia?
- Yes
- No
Do you wear contact lenses?
- Yes
- No

FOR WOMEN ONLY
Could you be pregnant?
- Yes
- No
Are you breastfeeding?
- Yes
- No
Are your menstrual cycles normal?
- Yes
- No
Birth control pills?
- Yes
- No
Depo-Provera?
- Yes
- No
Date of last shot
Menopausal/peri menopausal hormone replacement therapy?
- Yes
- No
Periodic acne flare-ups related to cycle?
- Yes
- No

Your Name*
Entering your name here acts as your signature
Date of Submission*
Date Format: MM slash DD slash YYYY

Empower Med Spa

53 Fairfax Road
St Albans, VT 05478

Phone: 802 528 2738

Hours of Operation

Mondays – 10am-5pm
Tuesdays – 10am-7pm
Wednesdays – 10am-5pm
Thursdays – 10am-7pm
Fridays – Every Other 12pm-4pm (please call for availability)
Saturdays – Closed

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