Name __________________________________________________________________________________________
Address ________________________________________________________________________________________
City _____________________________________________ State ________________ Zip _________________
E-Mail __________________________________________________________________________________________
___________________________Work______________________
Birthday ________________________________ Age ____________________________________________________
How did you hear about us? (If a friend, please give us their name so we can thank them!)
Your Skin
Do you have any special skin problems pertaining to your face or body?
If yes, please specify: ___________________________________________________________
Have you ever had problems with wax products?
If yes, please specify: ___________________________________________________________
Do you experience skin breakouts? yes no
Do you have a tendency toward redness? yes no
What are your skin care goals? _____________________________________________________
Exfoliation History
Have you had a chemical peel, microderm, or any resurfacing treatment in the last month? yes no
Do you use Accutane, Retin A, Renova, or any other prescription skin products? yes no
Are you currently using any products that contain the fol owing ingredients?
glycolic acid lactic acid exfoliating scrub hydroxy acid vitamin a derivatives
Sun Exposure
What spf sunscreen do you use on your face?____body?____
Do you sunbathe or use tanning beds? yes no
Allergies
Have you ever had an al ergy to nuts? ___________________
Have you ever had a reaction or an al ergy to any of the fol owing?
cosmetics medicine iodine waxing products wheat algae extract
Do you have al ergies to anything not listed above? ___________________________________________________
_____________________________________________________________________________________________
Your Health
Within the last year, have you been under a physician’s care?
If yes, please specify: ___________________________________________________________________________
List any prescription or over-the-counter medications, supplements, vitamins, etc., taken regularly: ______________
______________________________________________________________________________________________
Do you have metal implants, a pacemaker or body piercing?
Female Clients Only
Are you pregnant or trying to become pregnant?
I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be
relevant to my treatment. Please Note: Accutane, Retin A, Renova and anitbiotics can cause your skin to thin. Waxing and using
exfoliants while using these products can tear and could result in scaring. Please do not withhold this Information when asked by your
Client Signature _________________________________________ Date ______________ This intake form is to correctly evaluate your special skin care needs. This information is confidential and may be disclosed only to staff members, risk or quality improvement personnel to assess the quality of care and wil not be passed on to a third party.
JOURNAL OF CHINESE MEDICINE NUMBER 68 FEBRUARY 2002 TREATMENT BY CHINESE MEDICINE LIVER & GALLBLADDER BASED ERECTILE DYSFUNCTION (Part One) by Shawn Soszka Abstract been interest in the function and disease of the male repro-The purpose of this article is to demonstrate Liver/ ductive organ. It is this long-standing interest, and myGallbladder zangfu disharmony as a poss
1. Project Title: ASIC channel blockers; a potential target in the treatment of ALS Mentors: Dr. Áine Behan and Prof. Jochen Prehn, Department of Physiology and Medical Physics, RCSI. Proposed Project: Motoneuron degeneration and neurodegeneration in ALS are being increasingly linked to mitochondrial dysfunction and metabolic alterations (Adhihetty and Beal, 2008; Browne et al., 2006;