Questionnaire | JennyVElevatedBeauty

Are you over the age of 18?

No

Yes

Have you had any aspirin or blood thinning products within the last 7 days?

No

Yes

Any mood altering drugs within the last 8 hours? (i.e. Wellbutrin, Xanax, Prozac)

No

Yes

Do you have any history of cold sores, herpes, or fever blisters?

No

Yes

Are you sensitive to Latex?

No

Yes

Have you had a chemical laser peel?

No

Yes

Do you have problems with healing?

No

Yes

Previous problems with tanoos or has your physician advised you not to have a tanoo at this-time?

No

Yes

Are you currently undergoing radiation or chemotherapy?

No

Yes

Are'you currently taking any chemotherapy medications?

No

Yes

Are you currently using Retin-A or "Alpha Hydroxy" skin care products? (If so, avoid use for 1 month following procedure)

No

Yes

Do you wear contact lenses?

No

Yes

Are you allergic to any metal? (e.g. Can only wear 14k gold)

No

Yes

Have you ever had any permanent makeup procedures prior to this appt?

No

Yes

Medication, including immunosuppressive, such as anti-inflammatory or steroids?

No

Yes

Withdrawals from caffeine products?

No

Yes

Are you allergic to topical antibiotic numbing creams or desensitizers?

No

Yes

Is there any history of skin diseases or remarkable skin sensitivities?

No

Yes

In the last year have you had a baby?

No

Yes

Are you PREGNANT or NURSING?

No

Yes

Are you required to take antibiotics during dental or invasive medical procedures?

No

Yes

Are you required to take antibiotics during dental or invasive medical procedures?

No

Yes

Do you have any drug allergies? If yes, list in space provided at the end of the form.

No

Yes

Are you currently taking medication for Wgh or low blood pressure?

No

Yes

Did you work out today?

No

Yes

Have you consumed alcohol today?

No

Yes

Client Questionnaire

Client Questionnaire