Confidential Client Health History Form

  • Confidential Client Health History Form

  • Date
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Your Health

  • 1) Have you been under the care of a physician, dermatologist or other medical professional within the past year?
  • 2) Any recent surgery, including plastic surgery?
  • 3) Any skin cancer?
  • 4) Have you had any piercings, tattoos, or permanent cosmetics?
  • 5) Have you ever had a body spa treatment before?
  • 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)
  • 7) Has your physician discussed concerns about raising your body temperature?
  • 8) Do you smoke?
  • 9) Do you follow a restricted diet?
  • 10) Do you follow a regular exercise program?
  • 11) What is your stress level?
  • 12) Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid orRetinol/vitamin A derivative products?
  • 13) Have you used any of these products in the last 3 months?
  • 14) Have you used an acne medication?
  • 14) Have you used an acne medication?
  • 15) Do you form thick or raised scars from cuts or burns?
  • 16) Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?

  • List your daily consumption of:

  • 17) Do you experience any problems sleeping?
  • 19) Do you wear contact lenses?
  • 20) Have you been exposed to the sun or used a tanning bed in the last 48 hours?
  • 21) How frequently are you exposed to the sun or use a tanning bed?
  • 22) Do you have any metal implants or wear a pacemaker?
  • 23) Have you ever experienced claustrophobia?
  • 24) Do you suffer from sinus problems?
  • 25) Have you ever had an adverse reaction after using any skin care product? (Please check all that apply)
  • 26) Have you ever had an allergic reaction to any of the following? (Please check all that apply)

  • Female Clients Only:

  • 27) Are you taking oral contraceptives?
  • 28) Any recent changes to or from your contraceptive treatment?
  • 29) Are you pregnant or trying to become pregnant?
  • 30) Are you lactating?
  • 31) Any menopause problems?

  • 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.

  • Date*
     - -
  • Should be Empty: