* First Name
* Last Name
* Birthday
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
* Address Street 1
* Address Street 2
* Address City
* Address State
Any State
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
* 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?
No
Yes
* 2) Any recent surgery, including plastic surgery?
No
Yes
* If yes, please list procedure and date
* 3) Any skin cancer?
No
Yes
* 4) Have you had any piercings, tattoos, or permanent cosmetics?
No
Yes
* 5) Have you ever had a body spa treatment before?
No
Yes
* 6) Have you had any of these health conditions in the past or present?
Any active infection
Arthritis
Asthma
Blood clotting abnormalities
Cancer
Diabetes
Eczema
Epilepsy
Fever blisters
Frequent cold sores
Headaches (chronic)
Heart problem
Hepatitis
Herpes
High blood pressure
HIV/AIDS
Hormone imbalance
Hysterectomy
Immune disorders
Insomnia
Keloid scarring
Lupus
Metal bone pins or plates
Phlebitis, blood clots, poor circulation
Psychological treatment
Seizure disorder
Skin disease/skin lesions
Spinal injury
Systemic disease
Thyroid condition
Varicose veins
N/A
* 7) Has your physician discussed concerns about raising your body temperature?
No
Yes
* 8) Do you smoke?
No
Yes
* 9) Do you follow a restricted diet?
No
Yes
* 10) Do you follow a regular exercise program?
No
Yes
* 11) What is your stress level?
High
Medium
Low
* 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?
No
Yes
* 13) Do you use AHA, Saliciylic Acid, or Retinol/vitamin A derivative products?
No
Yes
* 14) Have you used any of these products in the last 3 months?
No
Yes
* 15) Have you used an acne medication?
No
Yes
* If so, when and which drug?
* 16) Do you form thick or raised scars from cuts or burns?
No
Yes
* 17) Do you have Hyperpigmentation (darkening of the skin)?
No
Yes
* 18) Do you have Hypopigmentation (lightening of the skin)?
No
Yes
* 19) Do you have any marks after physical trauma?
No
Yes
* 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?
No
Yes
* 21) How many hours do you typically sleep each night?
* 22) Do you wear contact lenses?
No
Yes
* 23) Have you been exposed to the sun or used a tanning bed in the last 48 hours?
No
Yes
* 24) How frequently are you exposed to the sun or use a tanning bed?
Infrequently
Frequently
Regularly
* 25) Do you have any metal implants or wear a pacemaker?
No
Yes
* 26) Have you ever experienced claustrophobia?
No
Yes
* 28) Have you ever had an adverse reaction after using any skin care product?
Breakout
Irritation
Peeling
Rash
Sun Sensitivity
* 29) Do you suffer from sinus problems?
No
Yes
* 29) Have you ever had an allergic reaction to any of the following?
AHAs
Animals
Cosmetics
Drugs
Food
Fragrance
Iodine
Latex
Medicine
Pollen
Shellfish
Sunscreens
* 30) Are you taking oral contraceptives?
No
Yes
* 31) Any recent changes to or from your contraceptive treatment?
No
Yes
* If yes, what and when?
* 32) Are you pregnant or trying to become pregnant?
No
Yes
* 33) Are you lactating?
No
Yes
* 34) Any menopause problems?
No
Yes
* If marked yes anywhere, please explain (please number answers to match the question number)
* Client Signature