Blooméra Skin LLC Intake Form
Client Intake/Medical Information
Full Name
First Name
Middle Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Today's Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Medical History
Under care of physician?
*
Please Select
Yes
No
Pacemaker?
Please Select
Yes
No
How would you like your experience to be ?
*
Educational & Relaxing
Just A Relaxing Experience
Electrical implants?
Please Select
Yes
No
Metal implants?
Please Select
Yes
No
Plates?
Please Select
Yes
No
Braces?
Please Select
Yes
No
No devices/implants?
Please Select
Yes
No
Medical Conditions
Hormone Imbalance
High Blood Pressure
Heart Problems
Auto-Immune Disorder
Epilepsy / Seizures
Diabetes
Thyroid Condition
Asthma
Cancer
Hepatitis
Kidney Disease
Liver Disease
Blood Disorder
Circulation Problems
Stroke
HIV
STD
Herpes
Active Sores
Other
Any allergies?
Are you allergic to aspirin?
Please Select
Yes
No
Are you on any medications/supplements?
Cystic acne medication?
Please Select
Yes
No
Client Intake History
Botox/Fillers in the past month?
*
Please Select
Yes
No
If yes, has it been less than 6 weeks?
*
Please Select
Yes
No
Are you claustrophobic or do you struggle with anxiety?
*
Please Select
Yes
No
Claustrophobia/Anxiety details
Stress Level
*
Are you pregnant or breastfeeding?
*
Please Select
Yes
No
Are you on birth control?
*
Please Select
Yes
No
Are you on any hormone replacements?
*
Please Select
Yes
No
Do you struggle with PCOS/PMOS?
*
Please Select
Yes
No
Have you currently or in the past two weeks had covid?
*
Please Select
Yes
No
Have you currently or in the past two weeks had a cold or flu like symptoms?
*
Please Select
Yes
No
Do you currently have a sunburn or open lesion?
*
Please Select
Yes
No
Will you be exposed to the sun in the next couple of days following your appointment?
*
Please Select
Yes
No
Client Treatment Questions
What products do you use at home?
Will this be your first facial?
*
Please Select
Yes
No
What are your skin concerns?
What are your skin goals?
How does your skin feel on the daily?
Skin type
Please Select
Dry
Normal
Oily
Combination
What does your daily routine consist of?
Cleanser
Toner
Mask
Serum
Exfoliant
Moisturizer
Sunscreen
Eye Cream
Other
Are you on any dermatologist prescriptions?
*
Please Select
Yes
No
If yes, dermatologist prescriptions details
Are you currently taking any prescriptions?
*
Please Select
Yes
No
Are you currently taking any of these medications? Isotretinoin, Retinoids,Topical acne creams,Benzoyl Peroxide,Salysilic acid,bloodthiners, or antibiotics?
*
Please Select
Yes
No
If yes, list current prescriptions
Any skin conditions diagnosed?
*
Please Select
Yes
No
If so, what is the diagnosis?
Have you been waxed/laser in the last 2 weeks?
*
Please Select
Yes
No
Additional skin care or treatment history notes
Submit
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