Confidential Client Health History Form
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name:
First Name
Last Name
Date Of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone:
Format: (000) 000-0000.
Business Phone:
Format: (000) 000-0000.
Cell Phone:
Format: (000) 000-0000.
E-mail:
example@example.com
Physician:
Format: (000) 000-0000.
Phone:
Format: (000) 000-0000.
Emergency Contact:
Format: (000) 000-0000.
Phone:
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?
No
Yes, explain:
2) Any recent surgery, including plastic surgery?
No
Yes, explain:
3) Any skin cancer?
No
Yes, explain:
4) Have you had any piercings, tattoos, or permanent cosmetics?
No
Yes, If yes, where on your person?
5) Have you ever had a body spa treatment before?
No
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)
Health Conditions
Cancer
Hormone imbalance
Systemic disease
High blood pressure
Spinal injury
Thyroid condition
Hysterectomy
Diabetes
Heart problem
Varicose veins
Arthritis
Asthma
Eczema
Epilepsy
Seizure disorder
Fever blisters
Headaches (chronic)
Hepatitis
Herpes
Frequent cold sores
Immune disorders
HIV/AIDS
Lupus
Metal bone pins or plates
Phlebitis, blood clots, poor circulation
Blood clotting abnormalities
Psychological treatment
Insomnia
Keloid scarring
Skin disease/skin lesions
Any active infection
7) Has your physician discussed concerns about raising your body temperature?
No
Yes
explain:
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Confidential Client Health History Form-continued
8) Do you smoke?
No
Yes
9) Do you follow a restricted diet?
No
Other
10) Do you follow a regular exercise program?
No
Yes
11) What is your stress level?
High
Medium
Low
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 or Retinol/vitamin A derivative products?
No
describe:
13) Have you used any of these products in the last 3 months?
No
Yes
14) Have you used an acne medication?
No
Which drug?
15) Do you form thick or raised scars from cuts or burns?
No
Yes
16) Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?
No
describe:
Water
Caffeine
Alcohol
17) Do you experience any problems sleeping?
No
Yes
18) How many hours do you typically sleep each night?
19) Do you wear contact lenses?
No
Yes
20) Have you been exposed to the sun or used a tanning bed in the last 48 hours?
No
Yes
21) How frequently are you exposed to the sun or use a tanning bed?
Infrequently
Frequently
Regularly
22) Do you have any metal implants or wear a pacemaker?
No
Yes
23) Have you ever experienced claustrophobia?
No
Yes
24) Do you suffer from sinus problems?
No
Yes
25) Have you ever had an adverse reaction after using any skin care product? (Please circle any that apply)
Rash
Irritation
Peeling
Sun Sensitivity
Breakout
26) Have you ever had an allergic reaction to any of the following? (Please circle any that apply and explain)
Cosmetics
Medicine
Food
Animals
Sunscreens
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex
Drugs
Other
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Confidential Client Health History Form-continued
If yes, please explain:
Female Clients Only:
27) Are you taking oral contraceptives?
No
Other
No
Yes
29) Are you pregnant or trying to become pregnant?
No
Yes
30) Are you lactating?
No
Yes
31) Any menopause problems?
No
Other
Please use this space to complete answers where space was insufficient. (Please include the number of the question)
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.
Client Signature:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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