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 Name Last Name
Date

Month Day Year
Date
Date Of Birth

Month Day Year
Date
Age
Occupation
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
Email Address
Emergency Contact Name

First Name Last Name
Emergency Contact Phone

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

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

Morning Noon Evening Weekends
MEDICAL HISTORY

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

Yes No
If so, for what?
Do you have any health concerns we need to know about (please check all that apply):

Cancer Diabetes High blood pressure Arthritis Frequent cold sores HIV/AIDS Keloid scarring Skin disease/Skin lesions Seizure disorder Hormone imbalance Thyroid imbalance Blood clotting abnormalities Any active infection
Current Medications:

Birth control pills Hormones Accutane Avita Differin Retin A Renova Glycolic Acid Triple Bleach Hydroquinone Antibiotics Coumadin
Are you on any anti-depression medication?

Yes No
If so please list type:
What herbal supplements do you use regularly?
Have you ever had an allergic reaction to any of the following?:

Food Latex Aspirin Lisocaine Hydrocortisone Hydroquinone or skin bleaching agents
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? *

Shaving Waxing Electrolysis Plucking Tweezing Stringing Depilatories
Have you had any recent tanning or sun exposure that changed the color of your skin?

Yes No
Have you recently used any self-tanning lotions or treatments?

Yes No
Do you form thick or raised scars from cuts or burns?

Yes No
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?

Yes No
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?

Yes No
Are you breast feeding?

Yes No
Are You using contraception?

Yes No
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.
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Date

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Date
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CLIENT INFORMATION & MEDICAL HISTORY

MEDICAL HISTORY

SKINCARE HISTORY