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Facial Health History
Your Information
Name
First
Last
Date of Birth
MM slash DD slash YYYY
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Street Address
Address Line 2
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Armed Forces Americas
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State
ZIP Code
Physician
Physician Phone
Emergency Contact
Emergency Contact Phone
Your Health
Have you been under the care of a physician, dermatologist or other medical professional within the past year?
Yes
No
Explain
Any recent surgery, including plastic surgery?
Yes
No
Explain
Any skin cancer?
Yes
No
Explain
Have you had any piercings, tattoos, or permanent cosmetics?
Yes
No
Where on your person?
Have you ever had a body spa treatment before?
Yes
No
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 pinsr 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
Explain
Do you smoke?
Yes
No
Do you follow a restricted diet?
Yes
No
Explain
Do you follow a regular exercise program?
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 any of these products in the last 3 months?
Yes
No
Explain
Have you used an acne medication?
Yes
No
When and which medication?
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
Explain
Daily water intake
Daily coffee intake
Daily alcohol intake
Do you experience any problems sleeping?
Yes
No
How many hours do you typically sleep each night?
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?
Rash
Irritation
Peeling
Sun Sensitivity
Breakout
Have you ever had an allergic reaction to any of the following?
Cosmetics
Medicine
Food
Animals
Sunscreens
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex Drugs
Other
Other:
Female Clients Only
Are you taking oral contraceptives?
Yes
No
Specify
Any recent changes to or from your contraceptive treatment?
Yes
No
Specify
Are you pregnant or trying to become pregnant?
Yes
No
Are you lactating?
Yes
No
Any menopause problems?
Yes
No
What and when?
Consent
I agree to the policy.
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.
