Client-Health-History (New)

Confidential Client Health History Form
Date

MonthDayYear
Date
Name
Date Of Birth

MonthDayYear
Date
Address
E mail
example@example.com
Phone
Emergency Contact
Phone
Have you been under the care of a physician, dermatologist or other medical professional within the past year?

YesNo
Explain:
Any recent surgery, including plastic surgery?

YesNo
Explain:
Any skin cancer?

YesNo
Explain:
Have you had any piercings, tattoos, or permanent cosmetics?

YesNo
If yes, where on your person?
5) Have you ever had a body spa treatment before?NoYes, when:
Have you ever had a body spa treatment before?

YesNo
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

Headaches (chronic)CancerHepatitisHormone imbalanceHerpesSystemic diseaseFrequent cold soresHigh blood pressureImmune disordersSpinal injuryHIV/AIDSThyroid conditionHysterectomyLupusMetal bone pins or platesDiabetesPhlebitis, blood clots, poor circulationHeart problemBlood clotting abnormalitiesVaricose veinsPsychological treatmentInsomniaAsthmaKeloid scarringEczemaSkin disease/ skin lesionsEpilepsyAny active infectionSeizure disorderFever blisters
Has your physician discussed concerns about raising your body temperature?

YesNo
Explain
Do you smoke?

YesNo
9 Do you follow a restricted diet?

YesNo
Yes, specify
Do you follow a regular exercise program?

YesNo
What is your stress level?

HighMediumLow
List any medications you take regularly
List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?

YesNo
Describe
Have you used any of these products in the last 3 months?

YesNo
Have you used an acne medication?

YesNo
When?
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
Describe
List your daily consumption: Water
Alcohol
Caffeine
Do you experience any problems sleeping?

YesNo
18) How many hours do you typically sleep each night?
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?

YesNo
Have you ever experienced claustrophobia?

YesNo
24) Do you suffer from sinus problems?NoYes
Do you suffer from sinus problems?

YesNo
25) Have you ever had an adverse reaction after using any skin care product? (Please circle any that apply)

Rash Irritation Peeling Sun Sensitivity Breakout
Have you ever had an adverse reaction after using any skin care product? (Please check any that apply)

RashIrritationPeelingSun sensitivityBreakout
26) Have you ever had an allergic reaction to any of the following? (Please circle any that apply and explain)
CosmeticsMedicineFoodAnimalsSunscreenIodinePollenAHAsFragranceShellfishLatexDrugs
Others
If yes, please explain
Female Clients Only:
Are you taking oral contraceptives?

YesNo
Specify:
Any recent changes to or from your contraceptive treatment?

YesNo
If so, what and when?
Are you pregnant or trying to become pregnant?

YesNo
Are you lactating?

YesYes
Any menopause problems?

YesNo
specify
Please use this space to complete answers where space was insufficient. (Please include the number of the question)
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.
Client Signature

Clear
Date

MonthDayYear
Date
Associated Skin Care Professionals
Should be Empty: