ON SKIN - Client Information and Medical History Intake Form

Client Information and Medical History
Client Name
Birthdate

MonthDayYear
Date
Date

MonthDayYear
Date
Address

Address

Street Address Line 2

City/StateState / Province

Zip
Email: (receive special offers)
example@example.com
Phone
Who can we thank for your referral?
Please answer the following questions. All information provided will be held in complete confidence.
General Skin Care
Do you have any particular concerns with your skin?
What skin care products are you currently using?
Cleanser
Toner
SPF
Eye Product
Serum/Moisturizer
Exfoliator
Other
Please check any of the following you are currently using or have within the last 4 weeks

AccutaneAlpha/Beta Hydroxy AcidBenzoyl PeroxideHydroquinoneRetinoid (Vitamin A derivatives) i.e. Retin A, Renova, DifferinSteroids/Cortisone creamsMetronidazoleAntibiotics
Other ointments to treat skin conditions?
Have you ever had an allergic reaction to any skin care products, cosmetics, iodine or Seaweed?

YesNo
If yes, please specify:
Have you seen a dermatologist in the last year?
Do you sun bathe or use tanning beds? (How often)
Do you burn easily?
How many 16oz bottles of water do you consume in a day?
How much alcohol a day?
How many 12oz cups of coffee/tea a day?
Do you smoke/vape?

YesNo
Do you exercise? How often?
What exercises do you do?
What is your typical diet?
How many hours a day do you spend in front of a screen?
What is your commute like?
How would you describe your level of use of everyday makeup coverage?
How many hours do you sleep per night?
Do you take vitamins and supplements?

YesNo
If so, please list:
How is your skin during the day?

Oily all overShiny in T-zoneTight, dry, FlakyRed/IrritatedOther
Medical History
Are you currently under the care of a physician?

YesNo
If yes, why?
List current medications
Do you have any of the following conditions? (Please check all that apply)

CancerThyroidDiabetesFrequent Cold SoresHigh Blood PressureHerpesHepatitisArthritisHIV/AIDSEpilepsyEczemaSkin pigmentationAutoimmuneRosaceaKeloid ScarsJoint replacementHormone imbalancePace-makerPsoriasisPlates/Implants/PinsDenturesStrokeShinglesDermatitisVitiligo
Have you had any of the following? (please check all that apply)

Cosmetic SurgeryMicrodermabrasionPermanent MakeupLaser ResurfacingDermaplaningPhoto FacialWaxingLED light therapyMicroneedlingChemical PeelsBotox/FillersMicroneedlingSkin Cancer
Treatment Date
Any complications?
Do you bruise easily?

YesNo
If yes, explain
Any other health problems or medical conditions we should be aware of before treatment?
Female Clients
Are you pregnant or possibly pregnant?

YesNo
Are you breastfeeding?

YesNo
Are you taking any type of hormones or birth control?
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.

The treatments I receive here are voluntary and I release ON SKIN and/or skin care professional from liability and assume full responsibilty thereof.
Date

MonthDayYear
Date
Printed Name
Should be Empty:

General Skin Care

Medical History

Female Clients