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Confidential Client Health History Form For All New Clients
Date
First Name
Last Name
DOB
Address
Address 1
Address 2
City
Zip / Postal Code
State / Province
Country
Phone
Email
Physician
Phone
Emergency Contact
Phone
Please answer all questions:
Have you been under the care of a physician, dermatologist, or other medical professionals within the past year?
Yes
No
Any recent surgery including plastic surgery?
Yes
No
Have you had any piercings, tattoos, or permanent cosmetics?
Yes
No
Have you ever had a body treatment before?
Yes
No
Has your physician discussed concerns about raising your body temperature?
Yes
No
Do you smoke?
Yes
No
Do you follow a restricted diet or exercise program?
Yes
No
List medications:
Use of any acne medications?
Yes
No
Do you have hyperpigmentation or hypopigmentation?
Yes
No
Do you experience any sleeping problems?
Yes
No
How many hours do you sleep at night?
Do you have metal implants or a pacemaker?
Yes
No
Do you have sinus problems?
Yes
No
Have you had any of these health conditions in the past or present?
Headache(chronic)
Hormone
Cancer
Imbalance Hepatitis
Herpes
High Blood Pressure
Frequent Cold Sores
Spinal Injury
Immune Disorders
Thyroid Condition
HIV/AIDS
Hysterectomy
Lupus
Diabetes
Metal bone pins or plates
Heart Problem
Asthma
Eczema
Fever Blisters
Phleitis/blood clots / poor circulation
Varicose veins
Blood Clotting Abnormalities
Arthritis
Psychological Treatment
Epilepsy
Skin Disease / Skin Lesions
Any active infection
Please answer all questions:
What is your stress level?
Low
Medium
High
List your daily consumption of:
Water
Caffeine
Alcohal
Exposure to sun/ tanning bed:
Infrequent
frequent
Regularly
Experience any of these adverse reactions after using any skincare products:
Rash
Irritation
Peeling
Sun sensitivity
Breakout
Have you had an allergic reaction to any of the following:
Choose an option
arrow&v
Female Clients Only:
Are you taking oral contraceptives?
Yes
No
Any recent changes to 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
Please use this extra space to elaborate (Include the number to the question)
I understand that withholding information or providing misinformation may result in contraindications or irritation to the skin from treatments received. I am aware that is my responsibility to inform my skin care professional 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 the skin care professional from liability and assume full responsibility thereof.
Print name
Your Signature
Clear
Submit
Thanks for submitting!
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