Patient Health History Form

Date *

MM

DD

YYYY

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone

(###)

###

####

Physician Phone

(###)

###

####

Emergency Contact Phone *

(###)

###

####

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

Yes

No

Any recent surgery, including plastic surgery? *

Yes

No

Any skin cancer? *

Yes

No

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

Yes

No

Have you ever had a body spa treatment before? *

Yes

No

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

(Please check all that apply and provide additional information in the space provided below)

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

Has your physician discussed concerns about raising your body temperature? *

Yes

No

Do you smoke? *

Yes

No

Do you follow a restricted diet? *

Yes

No

Do you follow a regular exercise program? *

Yes

No

What is your stress level? *

Low

Medium

High

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 any of these products in the last 3 months?

Yes

No

Have you used an acne medication? *

Yes

No

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 experience any problems sleeping? *

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

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

No

Have you ever experienced claustrophobia? *

Yes

No

Do you suffer from sinus problems? *

Yes

No

Have you ever had an adverse reaction after using any skin care product?

(Please mark any that apply)

Rash

Irritation

Peeling

Sun Sensitivity

Breakout

Have you ever had an allergic reaction to any of the following?

(Please mark any that apply and explain below.)

Cosmetics

Medicine

Food

Animals

Sunscreens

Iodine

Pollen

AHAs

Fragrance

Shellfish

Latex

Drugs

Are you taking oral contraceptives?

Yes

No

Any recent changes to or from your contraceptive treatment?

Yes

No

Are you pregnant or trying to become pregnant?

Yes

No

Are you lactating?

Yes

No

Any menopause problems?

Yes

No

Signature *

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

First Name

Last Name

Date of Signature: *

MM

DD

YYYY