Client Health History Form

*First Name
*Last Name
*Email
*Birthday
*Address Street 1
*Address Street 2
*Address City
*Address State
*Address Postal Code
Phone Number
*Physician Name
*Physician Phone Number	( ) -
*Emergency Contact Name
*Emergency Contact Phone	( ) -
*1) Have you been under the care of a medical professional within the last year?
*2) Any recent surgery, including plastic surgery?
*If yes, please list procedure and date
*3) Any skin cancer?
*4) Have you had any piercings, tattoos, or permanent cosmetics?
*5) Have you ever had a body spa treatment before?
*6) Have you had any of these health conditions in the past or present?
*7) Has your physician discussed concerns about raising your body temperature?
*8) Do you smoke?
*9) Do you follow a restricted diet?
*10) Do you follow a regular exercise program?
*11) What is your stress level?
*List any medications you take regularly
*List any over the counter medications (vitamins, asprin, etc.) you take regularly
*12) Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, or Glycolic Acid?
*13) Do you use AHA, Saliciylic Acid, or Retinol/vitamin A derivative products?
*14) Have you used any of these products in the last 3 months?
*15) Have you used an acne medication?
*If so, when and which drug?
*16) Do you form thick or raised scars from cuts or burns?
*17) Do you have Hyperpigmentation (darkening of the skin)?
*18) Do you have Hypopigmentation (lightening of the skin)?
*19) Do you have any marks after physical trauma?
*List your daily consumption of alcohol
*List your daily consumption of caffeine
*List your daily consumption of water
*20) Do you experience any problems sleeping?
*21) How many hours do you typically sleep each night?
*22) Do you wear contact lenses?
*23) Have you been exposed to the sun or used a tanning bed in the last 48 hours?
*24) How frequently are you exposed to the sun or use a tanning bed?
*25) Do you have any metal implants or wear a pacemaker?
*26) Have you ever experienced claustrophobia?
*28) Have you ever had an adverse reaction after using any skin care product?
*29) Do you suffer from sinus problems?
*30) Are you taking oral contraceptives?
*31) Any recent changes to or from your contraceptive treatment?
*If yes, what and when?
*32) Are you pregnant or trying to become pregnant?
*33) Are you lactating?
*34) Any menopause problems?
*If marked yes anywhere, please explain (please number answers to match the question number)
*Client Signature

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 contradictions 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.

In order to provide the best service to all our clients, we kindly request that you let us know at least 24 hours in advance if you need to cancel or reschedule an appointment before the scheduled service time. If such changes are not made, a fee equivalent to 50% of the service cost will be applied. The same fee will be incurred if you are 15 minutes or more late for the scheduled start time you will have to reschedule to another day and pay the no show fee.

Any cancellation or reschedule made less than 24 hours in advance will result in a cancellation fee. The amount of the fee will be equal to $25 per service canceled.

Client Health History Form

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