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First and last name

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Mobile number

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Email address

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Street address

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Apt, suite, etc. (optional)

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City

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State

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ZIP code

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Date:

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Name:

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Date Of Birth:

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Address:

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Cell Phone:

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Email:

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Emergency Contact:

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Emergency Contact's Phone number:

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

Yes

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Any recent surgery, including plastic surgery?

Yes

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Any skin cancer?

Yes

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Have you had any piercings, tattoos, or permanent cosmetics?

Yes

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Have you ever had a body spa treatment before?

Yes

Have you had any of these health conditions in the past or present?

Cancer

Hormone imbalance

Systemic disease

High blood pressure

Spinal injury

Thyroid condition

Hysterectomy

Diabetes

Heart Problem

Varicose Veins

Arthritis

Asthma

Eczema

Epilepsy

Seizure disorder

Fever blisters

Headaches (chronic)

Hepatitis

Herpes

Frequent cold sores

Immune disorders

HIV/AIDS

Lupus

Metal bone pins or plates

Phlebitis

blood clots

poor circulation

Blood clotting abnormalities

Psychological treatment

Insomnia

Keloid scarring

Skin disease/skin lesions

Any active infection

None of these

Has your physician discussed concerns about raising your body temperature?

Yes

Do you smoke?

Yes

Do you follow a restricted diet?

Yes

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Do you follow a regular exercise program?

Yes

What is your stress level?

High

Medium

Low

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Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?

Yes

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

Yes

Have you used an acne medication?

Yes

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Do you form thick or raised scars from cuts or burns?

Yes

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

Yes

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List your daily consumption of: Water

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List your daily consumption of: Caffeine

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List your daily consumption of: Alcohol

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Do you experience any problems sleeping?

Yes

Do you wear contact lenses?

Yes

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

Yes

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

Infrequently

Frequently

Regularly

Do you have any metal implants or wear a pacemaker?

Yes

Have you ever experienced claustrophobia?

Yes

Do you suffer from sinus problems?

Yes

Have you ever had a rash after using any skin care product?

Yes

Have you ever had irritation after using any skin care product?

Yes

Have you ever had peeling after using any skin care product?

Yes

Have you ever had sun sensitivity after using any skin care product?

Yes

Have you ever had a breakout after using any skin care product?

Yes

Have you ever had an allergic reaction to Cosmetics

Yes

Have you ever had an allergic reaction to Medicine

Yes

Have you ever had an allergic reaction to Food

Yes

Have you ever had an allergic reaction to Animals

Yes

Have you ever had an allergic reaction to Sunscreens

Yes

Have you ever had an allergic reaction to Iodine

Yes

Have you ever had an allergic reaction to Pollen

Yes

Have you ever had an allergic reaction to AHAs

Yes

Have you ever had an allergic reaction to Fragrance

Yes

Have you ever had an allergic reaction to Shellfish

Yes

Have you ever had an allergic reaction to Latex

Yes

Have you ever had an allergic reaction to Drugs

Yes

Please fill out this field.

Are you taking oral contraceptives? (female clients only)

Yes

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Any recent changes to or from your contraceptive treatment? (female clients only)

Yes

Please fill out this field.

Are you pregnant or trying to become pregnant? (female clients only)

Yes

Are you lactating? (female clients only)

Yes

Any menopause problems? (female clients only)

Yes

Please fill out this field.

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.

Yes

I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received.

Yes

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.

Yes

I understand the treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.

Yes

Face Odyssey Esthetics