Add your info
First and last name*
Mobile number*
Email address
Address
Apartment, suite or unit number
City
State
Postal code
Date:*
Name:*
Date Of Birth:*
Address:*
Cell Phone:*
Emergency Contact:*
Have you been under the care of a physician, dermatologist or other medical professional within the past year?*
Yes
No
If yes, explain:
Any recent surgery, including plastic surgery?*
Yes
No
If yes, please explain:
Any skin cancer?*
Yes
No
Have you had any piercings, tattoos, or permanent cosmetics?*
Yes
No
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
No
Do you smoke?*
Yes
No
What is your stress level?*
High
Medium
Low
List any medications you take regularly:
List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?*
Yes
No
Have you used an acne medication?*
Yes
No
If yes, when and which drug?
Do you form thick or raised scars from cuts or burns?*
Yes
No
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
Yes
No
Do you wear contact lenses?*
Yes
No
Have you been exposed to the sun or used a tanning bed in the last 48 hours?*
Yes
No
Do you have any metal implants or wear a pacemaker?*
Yes
No
Have you ever experienced claustrophobia?*
Yes
No
Do you suffer from sinus problems?*
Yes
No
Have you ever had a rash after using any skin care product?*
Yes
No
Have you ever had irritation after using any skin care product?*
Yes
No
Have you ever had peeling after using any skin care product?*
Yes
No
Have you ever had sun sensitivity after using any skin care product?*
Yes
No
Have you ever had a breakout after using any skin care product?*
Yes
No
Have you ever had an allergic reaction to Cosmetics*
Yes
No
Have you ever had an allergic reaction to Medicine*
Yes
No
Have you ever had an allergic reaction to Food*
Yes
No
Have you ever had an allergic reaction to Animals*
Yes
No
Have you ever had an allergic reaction to Sunscreens*
Yes
No
Have you ever had an allergic reaction to Iodine*
Yes
No
Have you ever had an allergic reaction to Pollen*
Yes
No
Have you ever had an allergic reaction to AHAs*
Yes
No
Have you ever had an allergic reaction to Fragrance*
Yes
No
Have you ever had an allergic reaction to Shellfish*
Yes
No
Have you ever had an allergic reaction to Latex*
Yes
No
Have you ever had an allergic reaction to Drugs*
Yes
No
If other, please specify:
Are you pregnant or trying to become pregnant? (female clients only)
Yes
No
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.*
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