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General Medical History Form
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Name
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First
Last
(IC) Identification Number / FIN
Occupation
What are your areas of concern?
Uneven Skin Tone
Acne Scarring / Acne
Melasma
Wrinkles Dry Skin
Crow’s Feet
Dark Circles
Dull Skin
Eczema
Skin Elasticity
Sun Damage
Dehydrated Skin
Cellulite
Sagging Skin
Others
If you have selected "others" Please state here
Pain Level
High
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My Skin Is :
Oily
Dry
Oily & Dry
Acne Prone
Any Allergies? (Please Leave Blank If None)
Any Major Illnesses? (Please Leave Blank If None)
Current Medications? (Please Leave Blank If None)
Please indicate for all current or past conditions that apply:
High/Low Blood Pressure
Varicose Veins/Bruising Broken Bones
Epilepsy
Asthma/Medication Diabetes Type I or II Numbness/Tingling Osteoporosis
Metal Rods/Plates/Screws Hepatitis A/B/C
Heart Condition/Disease
Hemophilia/Clotting Disorder
Arthritis
Immune Disorders
Sinus Problems
HIV/AIDS
Fibromyalgia Keloid Scarring Pacemaker Sinus Problems
Anxiety/Depression
Thyroid Condition
Cold Sores/Herpes/Shingles
Staph Infection
Sprains/Strains
Sleeping/Eating Disorders
Headaches/Migraines
Lupus
Fatigue/Dizziness/Vertigo
Other Medical Conditions (Please Explain If Any)
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EM Pulse Therapy
MagPulse Muscle Toning
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Acne / Lifting Treatments
EndyMed™ 3DEEP (Radio Frequency) RF
Exosome Facial
TAC Bojin Guasha Facial
Filgora Skin Booster (NCTF 135HA)
Skin Treatments
Hydrafacial™
Intraceuticals™ Oxygen Facial
EndyMed™ RF
md:peel
Exosome Facial
Thesera L (Thread Lift)
Rejuran
Lumi Shinkiso Wave
Misty LED Facial Therapy
TAC 24K Gold Facial
TAC Signature Facial
Mesotherapy Facial
Body Treatments
OxyNova™ Mild Hyperbaric
md:peel
New Doublo HIFU
Coolshaping2 Fat Freeze
EndyMed™ (RF)
Exosome Facial
QSculpting Pro (EM)
Needleless Thread Lift (Thesera)
CryoSnow SHR
QuadPulse Pelvic Chair
Hair Treatments
Hydrafacial™ Keravive
GLASH Lash & Brow Regrowth
CryoSnow SHR
Gentle Gold Brow & Lip Wax
Japans No.1 Teeth Whitening
Japan Teeth Whitening (美白)
VISIA Skin Analysis
QuadPulse Pelvic Chair Therapy
OxyNova™ Mild Hyperbaric
First Trial Deals
Media
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