ACQUA BLU MEDICAL SPA & PLASTIC SURGERY CENTER Skin Care History Please answer the following questions so that I may have a better understanding of your general health and can appropriately address your skin care needs. Please Print. Client name: __________________________________________________________
Address: _____________________________________________________________ Email Address: ________________________________________________________ Telephone #: (home) ______________________(work) ________________________ Age: _______under 21 ____21-30 ____31-40 ____41-50 ____51-60 ____60+ How did you hear about us? Please list: _____________________________________ Your Health 1. Within the last year, have you been under a plastic surgeon, dermatologist or other physician’s care?
2. Within the last nine months, have you undergone any surgery? ____ yes ____no 3. Have you had any health problems in the past or present? ____ yes ____no If yes, please specify___________________________________________ 4. List any medications, supplements, vitamins, diuretics, slimming tablets etc. that you take regularly________________________________________________________ 5. Do you smoke? ____ yes ____no 6. Do you exercise regularly? ____ yes ____no 7. Do you follow a restricted diet? ____yes ____no 8. Do you have metal implants, a pacemaker or body piercing? ____yes ____no 9. Do you wear contact lenses? ____yes ____no 10. Rate your level of stress on a scale of 1 to 4 (1=low stress, 4=high stress) _______ 11. Are you allergic to aspirin? ____yes ____no Do you have any other allergies? (including food and latex)?____________________________________________ Your Skin 12. Do you have any skin problems pertaining to your face or body? ____yes ____no If yes, please specify_______________________________________________ 13. What skincare products are you currently using? Face: ___soap ____cleanser ____toner ____moisturizer ____exfoliator ___eye product Body: ___soap ____cleanser ____toner ____moisturizer ____exfoliator ___eye product Exfoliation History 14. Have you ever had chemical peels, microdermabrasion, or any other resurfacing treatments? ____yes
15. Do you use Accutane, Retin A, Renova, Adapalene or any other prescription skin care products?
____yes ____no in the last three months ____yes ____no
16. Are you currently using any products that contain the following ingredients? ____glycolic acid ____lactic acid ____any exfoliating scrubs ____any hydroxyl acid products ____vitamin A derivatives (i.e. retinol)
page two Moisture Hydration 17. How much plain water do you consume daily? __________________ 18. How many alcoholic beverages do you consume weekly? _________ 19. Do you ever experience these conditions on your skin? ____ flakiness ____tightness ____ obvious dryness 20. What SPF sunscreen do you use on your face? ____ body? ____ 21. Do you sunbathe or use tanning beds? ____yes ____no Capillary Activity 22. Do you burn easily in moderate sunlight? ____yes ____no 23. Do you blush easily when nervous? ____yes ____no 24. Do you have a tendency to redness? ____yes ____no 25. Do you suffer from sinus problems? ____yes ____no Oil Secretion 26. Do you ever experience oily shine during the day? ____yes ____no 27. Do you ever experience skin breakouts? ____yes ____no Nerve Activity 28. Do you drink more than 4 caffeinated beverages daily? (coffee,tea,soft drinks) ____yes ____no 29. Do you ever experience a burning,itching sensation on your skin? ____yes ____no 30. What is your pain threshold? ____low ____medium ____high 31. Have you ever experienced claustrophobia? ____yes ____no 32. What type of massage pressure do you prefer? ____light ____medium ____firm 33. Have you ever had a reaction to the following? ____cosmetics ____iodine ____pollen ____ food ____hydroxyl acids ____animals ____fragrance ____sunscreen ____other Female Clients Only 34. Are you taking oral contraception? ____yes ____no 35. Are you pregnant or trying to become pregnant? ____yes ____no 36. Are you lactating? ____yes ____no Male Clients Only 37. What is your current shaving system? ____ electric ____wet shave 38. Do you experience irritation from shaving? ____yes ____no Questions to Discuss Every Visit 39. Are you currently having or due for your menstrual period? ____yes ____no 40. Have you started any new medication since your last visit? ____yes ____no 41. Have you had any recent dental x-rays? ____yes ____no 42. What are your skin care goals? __________________________________________ ___________________________________________________________________ Signature: _________________________________________Date:_________________ Please Print Name_________________________________________________________ Acqua Blu Medical Spa & Plastic Surgery Center 04/09
INTEGRATIONS FOR A PSYCHOLOGY WITHOUT BODY AND A NEUROLOGY WITHOUT SOUL Edith Liberman Its usual among us to state the theoretical or the conceptual deficiencies of the Bioenergetic Analysis and the necessity to build up sufficient theoretical framework to support our way of working. Do we have to invent a new theory? How can two categories that have developed separately, two
The School District of St. Lucie County SUPERINTENDENT 329 N.W. Commerce Park Drive Port St. Lucie FL 34986 Voice – (772)336-6980 Fax – (772)336-6985 Date: 4/8/08 ADDENDUM NO. 1 REQUEST FOR PROPOSAL NO . 08-30 TITLE: Administrative Services Only (ASO) for Self Funded Medical and Fully Insured Medical and Dental SCHEDULED OPENING DATE: ISSUED BY : Allen Lee, Pur