Modern Functional Health Medical Spa
Functional Medicine Doctor in St. Peters
Schedule Now
(636) 205-4070
Client Portal
Aesthetics
Laser Hair Removal
Laser Hair Removal
Darker Skin Tones LHR
Transgender Friendly LHR
Laser Hair Removal for PCOS
Fitzpatrick Scale Quiz
Laser Hair Removal Cost
LHR Popular Areas
Facial Rejuvenation
Oxygen Facial (Glo2Facial)
Threadlift
Fractora
Sublative
Co2
Lumecca IPL Photofacial
Hydrafacial
Microneedling
Skin Treatments
GentleMax Pro Treatments
Injectables
Cosmetic Injectables (Newtox)
Lip Flip
Botox for Excessive Sweating
Testosterone
Testosterone
Testosterone Replacement Therapy
Sexual Health
Women – Self Care
Let’s Talk About Sex
Vaginal Rejuvenation
Men
Testosterone Replacement Therapy
Functional Medicine
IV Therapy
Myers Cocktail
The Last Word Cocktail (Burn Fat)
Old Fashion (Hydrate)
Corpse Reviver Cocktail (Hangover)
Bee’s Knees Cocktail (Recovery)
Sidecar Cocktail (Immunity)
Ward 8 Cocktail (Beauty)
Pregnancy IV Therapy
Tri -Immune
B12
About
Spa Professionals
Dr. James Sturm
Spa Professionals
Patient Info
New Patient Forms
Testimonials
Blog
Before & After
Contact
Aesthetics Intake Form
Name
(Required)
First
Last
Date of Birth
(Required)
Month
Day
Year
Address
(Required)
Street Address
City
ZIP / Postal Code
Phone
(Required)
Email
(Required)
Occupation
(Required)
Referred By
(Required)
Medical History
Are you or is it possible that you may be pregnant?
(Required)
Yes
No
Are you breastfeeding?
(Required)
Yes
No
Do you form thick or raised scars from cuts or burns?
(Required)
Yes
No
After injury to the skin (such as cuts/burns) do you have
(Required)
Darkening of the skin in that area (hyperpigmentation)
Lightening of the skin in that area (hypopigmentation)
No
Hair removal by plucking, waxing, or electrolysis in the past 4 weeks?
(Required)
Yes
No
Hair removal by plucking, waxing, or electrolysis in the past 4 weeks?
(Required)
Yes
No
Tanning (tanning bed) or sun exposure in the last 4 weeks?
(Required)
Tanning
Sun exposure
No
Tanning products or spray on tan in the last 2 weeks?
(Required)
Yes
No
Do you have a tan now in the area to be treated?
(Required)
Yes
No
Do you use sunscreen daily with spf 30 or higher?
(Required)
Yes
No
History of skin cancer or unusual moles?
(Required)
Yes
No
Have you ever had a photosensitive disorder? (E.g. Lupus)
(Required)
Yes
No
History of seizures?
(Required)
Yes
No
Permanent make-up or Tattoos?
(Required)
Yes
No
Have you used Accutane in the last 6 months?
(Required)
Yes
No
Are you currently taking antibiotics?
(Required)
Yes
No
Are you using Retin-A or Glycolic products?
(Required)
Retin-A
Glycolic
No
Are you currently under the care of a physician?
(Required)
Yes
No
Do you currently smoke?
(Required)
Yes
No
Do you have an allergy or sensitivity to the following?
(Required)
Lidocaine
Latex
Sulfa Medications
Hydroquinone
Aloe
Bee Stings
No
Life threatening allergy to anything?
(Required)
Yes
No
Do you have scars on the face?
(Required)
Yes
No
Explanation Of Items Marked "Yes"
(Required)
Medical Conditions Past or Present
Keloid Scarring?
(Required)
Yes
No
Cold Sores?
(Required)
Yes
No
Herpes (genital)
(Required)
Yes
No
Easy Bruising or Bleeding?
(Required)
Yes
No
Active Skin Infection?
(Required)
Yes
No
Moles That Changed, Itched, or Bled?
(Required)
Yes
No
Recent Increase In The Amount Of Hair?
(Required)
Yes
No
Asthma?
(Required)
Yes
No
Seasonal Allergies/ Allergic Rhinitis?
(Required)
Yes
No
Eczema?
(Required)
Yes
No
Thyroid Imbalance?
(Required)
Yes
No
Poor Healing?
(Required)
Yes
No
Diabetes?
(Required)
Yes
No
Heart Condition?
(Required)
Yes
No
High Blood Pressure?
(Required)
Yes
No
Pacemaker?
(Required)
Yes
No
Disease Of Nerves Or Muscles?
(Required)
Yes
No
Cancer?
(Required)
Yes
No
HIV/AIDS?
(Required)
Yes
No
Autoimmune Disease?
(Required)
Yes
No
Hepatitis?
(Required)
Yes
No
Shingles?
(Required)
Yes
No
Migraine Heacaches?
(Required)
Yes
No
Other Illness, Health Problems, Or Medical Conditions Not listed?
(Required)
No
Other
Explanation Of Items Marked "Yes"
(Required)
Consent
(Required)
I Certify That The Medical Information I Have Given Is Complete And Accurate
Date
(Required)
Month
Day
Year
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