BEAUTY KULTURE STUDIO & ACADEMY CLIENT HEALTH HISTORY FORM

BEAUTY KULTURE STUDIO & ACADEMY

CLIENT HEALTH HISTORY AND QUESTIONNAIRE
Name*

First NameLast Name
Email*
example@example.com
Date of Birth*

MonthDayYear
Phone Number*

Area CodePhone Number
What is your Occupation?
Have you ever had any of the following conditions (Please check all that apply):

AlopeciaAsthmaBlephartitisBack PainCancer/Chemotherapy/RadiationCardiac ArrestClaustrophobiaCurrent Eye IrritationDiabetesDry EyeEating DisorderEpilepsyHormonal ImbalanceLight/UV SensitivityIntense StressMigrainesPacemakerRecent Eye SurgeryRosaceaSensitive EyesStrokeThyroid DiseasePregnancyWatery EyesStyeAllergies
Please list any allergies you have:
Including but not limited to allergies to food, medication, cosmetic ingredients.
Have you ever had a reaction to adhesive tape, topical creams, nail adhesive or any other topical products?*

YesNo
If yes, please explain:
Are you allergic to Acrylate/Cyanoacrylate (bonding agent)*

YesNo
Do you wear contact lenses?*

YesNo
Do you use Retin-A or Accutane?*

YesNo
Do you go tanning?*

YesNo
Do you receive facial services frequently?*

YesNo
Do you receive chemical peels or use any Alpha-hydroxy Acids or Retinol (Skin Lightening/Brightening) products?*

YesNo
If you receive chemical peels or use any Alpha/Beta Hydroxy Acids or Retinol, when was your most recent use of the product? (today, last week, two weeks ago, one month ago or more).
Have you had Botox or any other injections?*

YesNo
If you've had Botox or any other injections, what was the date of your last treatment?
Do you use Latisse or lash growth products?*

YesNo
Do you have any disease/disorder/condition/injury that has affected your hair or lash growth or loss in any way? If so, please explain below:*
Please list all medications you are currently taking, including but not limited to over the counter, herbs, vitamins and supplements.
Please provide your Signature here:*

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