Confidential Client Health History Form
Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Birth Year
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
1. Have you been under the care of a physician, dermatologist or other medical professional within the past year?
Yes
No
If yes, please explain
2. Any recent surgery, including plastic surgery?
Yes
No
If yes, please explain
3. Any skin cancer?
Yes
No
If yes, please explain
4. Have you had any piercings, tattoos, or permanent cosmetics?
Yes
No
If yes, where on your person?
5. Have you ever had a body spa treatment before?
Yes
No
If yes, when?
6. 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 below.
Cancer
Hormone Imbalance
Systemic Disease
High Blood Pressure
Spinal Injury
Thyroid Condition
Hysterectomy
Diabetes
Heart Problem
Varicose Veins
Arthritis
Asthma
Eczema
Epilepsy
Seizure Disorder
Fever Blisters
Headaches (chronic)
Hepatitis
Herpes
Frequent Cold Sores
Immune Disorders
HIV/AIDS
Lupus
Metal bone pins or plates
Phlebitis, blood clots, poor circulation
Blood clotting abnormalities
Psychological treatment
Insomnia
Keloid scarring
Skin disease/skin lesions
COVID-19
Any active Infection
Other
Additional Information
7. Has your physician discussed concerns about raising your body temperature?
Yes
No
8. Do you smoke?
yes
no
9. Do you follow a restrictive diet?
yes
no
If yes, please explain
10. Do you follow a regular exercise program?
yes
no
11. What is your stress level?
High
Medium
Low
12. List any medications you take regularly
13. List any over the counter medications (incl. vitamins, herbal supplements, aspirin, etc.) you take regularly
14. Do you use Retin-A, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?
yes
no
If yes, please describe and state the last time you used them (if within the last three months)
15. Have you used an acne medication?
Yes
No
If yes, when and which drug
16. Do you form thick or raised scars from cuts or burns?
Yes
No
17. Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?
Yes
No
If yes, please explain
18. List your daily consumption of
Water
Caffeine
Alcohol
19. Do you experience problems sleeping?
Yes
No
20. How many hours do you sleep each night?
21. Do you wear contact lenses?
Yes
No
22. Have you been exposed to the sun or used a tanning bed in the last 48 hours?
Yes
No
23. How frequently are you exposed to the sun or use a tanning bed?
Infrequently
Frequently
Regularly
24. Do you have any metal implants or wear a pace maker?
Yes
No
25. Have you ever experienced claustrophobia?
Yes
No
26. Do you suffer from sinus problems?
Yes
No
27. Have you ever had an adverse reaction after using any skin care product? Please can any that apply.
Rash
Irritation
Peeling
Sun Sensitivity
Breakout
28. Have you ever had an allergic reaction to any of the following? Please check any that apply.
Cosmetics
Medicine
Food
Animals
Sunscreen
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex
Drugs
Other
If yes, please explain
Female Clients Only
29. Are you taking oral contraceptives?
Yes
No
If yes, please explain
30. Any recent changes to or from your contraceptive treatment?
Yes
No
If yes, please explain
31. Are you pregnant or trying to become pregnant?
Yes
No
32. Are you lactating?
Yes
No
33. Any menopause problems?
Yes
No
If yes, please explain
34. What areas of concern do you have?
Please use this space to complete answers where space was insufficient. (Please include the number of the questions)
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.
*
Signature
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