Add your info
First and last name*
Mobile number
Email address
Date:*
Name:*
Date Of Birth:*
Address:*
Cell Phone:*
Email:*
Emergency Contact:*
Emergency Contact's Phone number:*
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
If yes, please explain further:
Have you had any piercings, tattoos, or permanent cosmetics?*
Yes
No
If yes, where on your person?
Have you ever had a body spa treatment before?*
Yes
No
If yes, when?
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
Do you smoke?*
Yes
No
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
If yes, describe:
Have you used any of these products in the last 3 months?*
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
If yes, describe further:
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
How frequently are you exposed to the sun or use a tanning bed?
Infrequently
Frequently
Regularly
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 Fragrance*
Yes
No
Have you ever had an allergic reaction to Drugs*
Yes
No
If you answered 'yes' to any of the above, please provide additional details:
Are you taking oral contraceptives? (female clients only)
Yes
No
If yes, specify (female clients only)
Are you pregnant or trying to become pregnant? (female clients only)
Yes
No
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