Confidential Client Health History Relax Your Body ~ Rejuvenate Your Mind ~ Renew Your Spirit. Please enable JavaScript in your browser to complete this form.Date *Name *Date of Birth *Address *Cell Phone: *Email *Phone *Emergency Contact *Phone *Your Health1) Have you been under the care of a physician, dermatologist or other medical professional within the past year? *NoYesExplain: *2) Any recent surgery, including plastic surgery? *NoYesExplain * 3) Any skin cancer? *NoYesExplain *4) Have you had any piercings, tattoos, or permanent cosmetics?NoYesIf yes, where on your person?5) Have you ever had a body spa treatment before?NoYesWhen? *6) Have you had any of these health conditions in the past or present?CancerHormone imbalance Systemic diseaseHigh blood pressure Spinal injury Thyroid conditionHysterectomyDiabetesHeart problemVaricose veinsArthritisAsthmaEczemaEpilepsySeizure disorder Fever blistersHeadaches (chronic) HepatitisHerpesFrequent cold sores Immune disorders HIV/AIDS LupusMetal bone pins or platesPhlebitis, blood clots, poor circulation Blood clotting abnormalitiesPsychological treatmentInsomniaKeloid scarringSkin disease/skin lesionsAny active infection (Please check all that apply and provide additional information in the space provided) 8) Do you smoke?YesNo9) Do you follow a restricted diet?YesNoSpecify10) Do you follow a regular exercise program?YesNo11) What is your stress level?High MediumLowList any medications you take regularly *List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly *12) Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?YesNoDescribe13) Have you used any of these products in the last 3 months? *YesNo14) Have you used an acne medication?YesNoWhenWhich drug?15) Do you form thick or raised scars from cuts or burns? YesNo16) Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma? *YesNoDescribe: When?List your daily consumption of Caffeine17) Do you experience any problems sleeping? NoYes18) How many hours do you typically sleep each night? *19) Do you wear contact lenses? NoYes20) Have you been exposed to the sun or used a tanning bed in the last 48 hours? *NoYes21) How frequently are you exposed to the sun or use a tanning bed? InfrequentlyFrequentlyRegularly22) Do you have any metal implants or wear a pacemaker?YesNo23) Have you ever experienced claustrophobia?YesNo24) Do you suffer from sinus problems?YesNo25) Have you ever had an adverse reaction after using any skin care product? DehydratedRashIrritationPeelingSun SensitivityBreakout(Please circle any that apply) 26) Have you ever had an allergic reaction to any of the following? (CosmeticsMedicineFoodAnimalsSunscreensIodinePollenAHAsFragranceShellfishLatexDrugsOther(Please circle any that apply & Explain) Please Explain *Please use this space to complete answers where space was insufficient. (Please include the number of the question)Checkboxes *I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the esthetician/skin care therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.Date *Submit Book Services Or Contact us
