Client Health History Form

*First Name
*Last Name
*Birthday
*Address Street 1
*Address Street 2
*Address City
*Address State
*Address Postal Code
*Email
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?
*29) Have you ever had an allergic reaction to any of the following?
*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 contradicitons 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 Health History Form

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