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Have you been under the care of a physician, dermatologist or other medical professional within the past year?*
Any recent surgery, including plastic surgery?*
If yes, please explain further:
Have you had any piercings, tattoos, or permanent cosmetics?*
If yes, where on your person?
Have you ever had a body spa treatment before?*
Have you had any of these health conditions in the past or present?*
Has your physician discussed concerns about raising your body temperature?*
Do you follow a restricted diet?*
If you do, please specify:
Do you follow a regular exercise program?*
What is your stress level?*
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?*
Have you used any of these products in the last 3 months?*
Have you used an acne medication?*
If yes, when and which drug?
Do you form thick or raised scars from cuts or burns?*
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
If yes, describe further:
Do you experience any problems sleeping?*
Do you wear contact lenses?*
Have you been exposed to the sun or used a tanning bed in the last 48 hours?*
How frequently are you exposed to the sun or use a tanning bed?
Do you have any metal implants or wear a pacemaker?*
Have you ever experienced claustrophobia?*
Do you suffer from sinus problems?*
Have you ever had a rash after using any skin care product?*
Have you ever had irritation after using any skin care product?*
Have you ever had peeling after using any skin care product?*
Have you ever had sun sensitivity after using any skin care product?*
Have you ever had a breakout after using any skin care product?*
Have you ever had an allergic reaction to Cosmetics*
Have you ever had an allergic reaction to Medicine*
Have you ever had an allergic reaction to Food*
Have you ever had an allergic reaction to Animals*
Have you ever had an allergic reaction to Sunscreens*
Have you ever had an allergic reaction to Iodine*
Have you ever had an allergic reaction to Pollen*
Have you ever had an allergic reaction to AHAs*
Have you ever had an allergic reaction to Fragrance*
Have you ever had an allergic reaction to Shellfish*
Have you ever had an allergic reaction to Latex*
Have you ever had an allergic reaction to Drugs*
If other, please specify:
Are you taking oral contraceptives? (female clients only)
If yes, specify (female clients only)
Any recent changes to or from your contraceptive treatment? (female clients only)*
If so, what and when? (female clients only)
Are you pregnant or trying to become pregnant? (female clients only)
Are you lactating? (female clients only)
Any menopause problems? (female clients only)
If yes, please be specific: (female clients only)
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.*
I understand that withholding information or providing misinformation may result in contraindications 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.*
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.*