Client Health History Form

1)Have you been under the care of a physician, dermatologist or other medical professional within the past year? NoYes

Explain:

2)Any recent surgery, including plastic surgery? NoYes

Explain:

3)Any skin cancer? NoYes

Explain:

4)Have you had any piercings, tattoos, or permanent cosmetics? NoYes

If yes, where on your person?:

5)Have you ever had a body spa treatment before? NoYes

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) CancerHormone imbalanceSystemic diseaseHigh blood pressureSpinal injuryThyroid conditionHysterectomyDiabetesHeart problemVaricose veinsArthritisAsthmaEczemaEpilepsySeizure disorderFever blistersHeadaches (chronic)HepatitisHerpesFrequent cold soresImmune disordersHIV/AIDSLupusMetal bone pins or platesPhlebitis, blood clots, poor circulationBlood clotting abnormalitiesPsychological treatmentInsomniaKeloid scarringSkin disease/skin lesionsAny active infection

7)Has your physician discussed concerns about raising your body temperature? NoYes

Explain:

8)Do you smoke? NoYes

9)Do you follow a restricted diet? NoYes

Specify:

10)Do you follow a regular exercise program? NoYes

11)What is your stress level? HighMediumLow

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? NoYes

Describe:

13)Have you used any of these products in the last 3 months? NoYes

14)Have you used an acne medication? NoYes

When?: Which drug?:

15) Do you form thick or raised scars from cuts or burns? NoYes

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

Describe:

List your daily consumption of:

Water

Caffeine

Alcohol

17) Do you experience any problems sleeping? NoYes

18) How many hours do you typically sleep each night?

19) Do you wear contact lenses? NoYes

20) Have you been exposed to the sun or used a tanning bed in the last 48 hours? NoYes

21) How frequently are you exposed to the sun or use a tanning bed? InfrequentlyFrequentlyRegularly

22) Do you have any metal implants or wear a pacemaker? NoYes

23) Have you ever experienced claustrophobia? NoYes

24) Do you suffer from sinus problems? NoYes

25) Have you ever had an adverse reaction after using any skin care product? RashIrritationPeelingSun SensitivityBreakout

26) Have you ever had an allergic reaction to any of the following? CosmeticsMedicineFoodAnimalsSunscreensIodinePollenAHAsFragranceShellfishLatexDrugsOther

27) Are you taking oral contraceptives? NoYes

Specify:

28) Any recent changes to or from your contraceptive treatment? NoYes

If so, what and when?

29) Are you pregnant or trying to become pregnant? NoYes

30) Are you lactating? NoYes

31) Any menopause problems? NoYes

Specify:

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.

1901 NC 16 Business, Denver, NC 28037

Client Health History Form

Your Health

Female Clients Only

1901 NC 16 Business, Denver, NC 28037