CLIENT INFORMATION & MEDICAL HISTORY

CLIENT INFORMATION & MEDICAL HISTORY

In order to provide you with the most appropriate aesthetic treatment, we need you to complete the following questionnaire. All information is strictly confidential.
Full Name*

First NameLast Name
Date

MonthDayYear
Date
Date Of Birth

MonthDayYear
Date
Age
Occupation
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Email Address
Emergency Contact Name

First NameLast Name
Emergency Contact Phone

Area CodePhone Number
How were you referred to us?
How Would You like to receive information from the Spa?

TextCallEmail
What is the best time of day for us to follow up with you after your treatment?

MorningNoonEveningWeekends
MEDICAL HISTORY

Please fill this out to the best of your ability:
Are you currently under the care of a physician?

YesNo
If so, for what?
Do you have any health concerns we need to know about (please check all that apply):

CancerDiabetesHigh blood pressureArthritisFrequent cold soresHIV/AIDSKeloid scarringSkin disease/Skin lesionsSeizure disorderHormone imbalanceThyroid imbalanceBlood clotting abnormalitiesAny active infectionOther
Current Medications:

Birth control pillsHormonesAccutaneAvitaDifferinRetin ARenovaGlycolic AcidTriple BleachHydroquinoneAntibioticsCoumadinOther
Are you on any anti-depression medication?

YesNo
If so please list type:
What herbal supplements do you use regularly?
Have you ever had an allergic reaction to any of the following?:

FoodLatexAspirinLisocaineHydrocortisoneHydroquinone or skin bleaching agentsOther
If you selected yes, please describe the reaction you experienced:
SKINCARE HISTORY

What brand of product are you currently using?
Have you used any of the following hair removal methods in the past six weeks?*

ShavingWaxingElectrolysisPluckingTweezingStringingDepilatoriesOther
Have you had any recent tanning or sun exposure that changed the color of your skin?

YesNo
Have you recently used any self-tanning lotions or treatments?

YesNo
Do you form thick or raised scars from cuts or burns?

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

YesNo
If you selected yes, please describe:
When was your last facial care treatment?
When was your last body care treatment?
What are you expecting from your facial and/or body care treatment today?
Are you pregnant or trying to become pregnant?

YesNo
Are you breast feeding?

YesNo
Are You using contraception?

YesNo
Additional Information and comments:
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.
Signature*
Date

MonthDayYear
Date
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CLIENT INFORMATION & MEDICAL HISTORY

MEDICAL HISTORY

SKINCARE HISTORY