Client health history

Name

First NameLast Name

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Emergency contact

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Have you been under the care of a dermatologist, physician, or any other medical professional within the past year?

If yes, explain and give details

Any recent surgeries, including plastic surgery?

If yes, explain

Any skin cancer?

Have you ever had any of these health conditions in the past or present?

Has your physician discussed concerns about you raising your body temperature? Yes or no? If yes explain

What is your stress level

Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products

If yes when was the last time and explain how often.

Have you used any acne medications?

If yes, when ? Which drug?

Do you form thick raised scars from cuts or burns?

Do you have hyperpigmentation or hypopigmentation or marks after physical trauma?

Do you have any sensitivities or allergies to essential oils &/ or herbal plants ?

Other

If yes , please list all

Do you experience any problems sleeping?

How many hours a night do you sleep?

Do you wear contact lenses ?

Have you been exposed to the sun or tanning bed in the last 48 hours ?

Please explain which type of exposure was it, are you experiencing peeling, burning or any other adverse reactions?

Do you have any metal implants or wear a pacemaker?

Have you ever had an adverse reaction after using any skin care products? Please Choose all that apply

Which products?

Have you ever had an allergic reaction to any of the following? Please check all that apply.

If yes explain

Are you taking any oral contraceptives? If yes explain

Are you pregnant or trying to become pregnant

Are you lactating?

Any menopause problems?

If yes, explain

Please use this space to leave any other information you feel I should know prior to treatment

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

Date

Form

Health History

Female clients only