Medical Questionnaire

Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
E-mail*
example@example.com
Phone Number*

Area CodePhone Number
Date of Birth*

MonthDayYear
Emergency Contact *
Emergency Contact Number*
Your Health
Have you been under the care of a physician, dermatologist or other medical professional within the past year please answer yes or no, if yes explain? *
Any recent surgery, including plastic surgery? please answer yes or no, if yes explain?*
Any skin cancer? please answer yes or no, if yes explain? *
Have you had any piercings, tattoos, or permanent cosmetics? If yes, where?*
Have you ever had a body spa treatment before? please answer yes or no, if yes when? *
Have you had any of these health conditions in the past or present?(Please check all that apply and provide additional information in the space provided)

CancerHormone imbalanceSystemic diseaseHigh blood pressureSpinal injuryThyroid conditionHysterectomyDiabetesHeart problemVaricose veinsArthritisAsthmaEczemaEpilepsySeizure disorderFever blistersHeadaches (chronic)HepatitisHerpesFrequent cold soresImmune disordersHIV/AIDSLupusMetal bone pins or platesPhlebitis, blood clots, poor circulationBlood clotting abnormalitiesPsychological treatmentInsomniaKeloid scarringSkin disease/skin lesionsAny active infectionNONEOther
(Provide additional information in the space provided)
Have you had any of these health conditions in the past or present? Please check all that apply*

CosmeticsMedicineFoodAnimalsSunscreensIodinePollenAHAsFragranceShellfishLatexDrugsNONEOther
(Provide additional information in the space provided)
Has your physician discussed concerns about raising your body temperature?*

YesNo
Do you follow a restricted diet?*

YesNo
Do you follow a regular exercise program?*

YesNo
What is your stress level?*

HighMediumLow
List ALL medications you take regularly:*
List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:*
Do you use any of the following Medications?*

Retin-A(Tretinoin)RenovaAdapalene Hydroxyl AcidDifferinGlycolic AcidAHASalicylic AcidRetinol/vitamin A derivative productsNONE
Have you used any of these products above in the last 3 months?*

YesNo
Have you ever had an adverse reaction after using any skin care product?*

RashIrritationPeelingSun SensitivityBreakoutNONE
Have you used an acne medication? If Yes, when? and Which drug?*
Do you form thick or raised scars from cuts or burns?*

YesNo
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*

YesNo
Do you experience any problems sleeping?*

YesNo
Do you wear contact lenses?*

YesNo
Have you been exposed to the sun or used a tanning bed in the last 48 hours?*

YesNo
How frequently are you exposed to the sun or use a tanning bed?*

InfrequentlyFrequentlyRegularly
Do you have any metal implants or wear a pacemaker?*

NoYes
Have you ever experienced claustrophobia?*

NoYes
Do you suffer from sinus problems?*

NoYes
Are you taking oral contraceptives?*

YesNo
Are you pregnant or trying to become pregnant?*

YesNo
Are you lactating?*

YesNo
Any menopause problems?*

YesNo
Any recent changes to or from your contraceptive treatment? If yes please explain?
How many hours do you typically sleep each night?
Do you ever have problems sleeping?*

YesNo
Do you have any other medical condition, injury or anything else we should be aware of that we have not mentioned?*

YesNo
Please provide details
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. PLEASE ENTER YOUR NAME BELOW.*
Date

MonthDayYear
Date
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Your Health