Confidential Client Health History Form

Confidential Client Health History Form
Date

MonthDayYear
Date
Name

First NameLast Name
Date of Birth
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Physician
Phone Number
Please enter a valid phone number.
Emergency Contact
Phone Number
Please enter a valid phone number.
Your Health
1) Have you been under the care of a physician, dermatologist or other medical professional within the past year?

YesNo
If yes, explain:
2) Any recent surgery, including plastic surgery?

YesNo
If yes, explain:
3) Any skin cancer?

YesNo
If yes, explain:
4) 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?

YesNo
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 provided)

CancerHormone imbalanceSystemic diseaseHigh blood pressureSpinal injuryThyroid conditionHysterectomyDiabetesHeart problemVaricose veinsArthritisAsthmaEczemaEpilepsyEpilepsyFever blistersHeadaches (chronic)HepatitisHerpesFrequent cold soresImmune disordersHIV/AIDSLupusMetal bone pins or platesPhlebitis, blood clots, poor circulationBlood clotting abnormalitiesPsychological treatmentInsomniaKeloid scarringSkin disease/skin lesionsAny active infection
7) Has your physician discussed concerns about raising your body temperature?

YesNo
If yes, explain:
8) Do you smoke?

YesNo
9) Do you follow a restricted diet?

YesNo
If yes, specify:
10) Do you follow a regular exercise program?

YesNo
11) 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:
12) Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid orRetinol/vitamin A derivative products?

YesNo
If yes, describe:
13) Have you used any of these products in the last 3 months?

YesNo
14) Have you used an acne medication?

YesNo
14) Have you used an acne medication?

YesNo
If yes, when?
Which drug?
15) Do you form thick or raised scars from cuts or burns?

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

YesNo
If yes, describe?
List your daily consumption of:
Water
Caffeine
Alcohol
17) Do you experience any problems sleeping?

YesNo
18) How many hours do you typically sleep each night?
19) Do you wear contact lenses?

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

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

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

YesNo
23) Have you ever experienced claustrophobia?

YesNo
24) Do you suffer from sinus problems?

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

RashIrritationPeelingSun SensitivityBreakout
26) Have you ever had an allergic reaction to any of the following? (Please check all that apply)

CosmeticsMedicineFoodAnimalsSunscreensIodinePollenAHAsFragranceShellfishLatexDrugsOther
If yes, explain?
Female Clients Only:
27) Are you taking oral contraceptives?

YesNo
If yes, specify?
28) Any recent changes to or from your contraceptive treatment?

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

YesNo
30) Are you lactating?

YesNo
31) Any menopause problems?

YesNo
If so, specify?
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.
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Confidential Client Health History Form

Your Health

Female Clients Only: