Confidential Client Health History Form

Confidential Client Health History Form
Date:

MonthDayYear
Name:
Date Of Birth:

MonthDayYear
Address:
Home Phone:
Business Phone:
Cell Phone:
E mail:
example@example.com
Physician:
Phone:
Emergency Contact:
Phone:
Your Occupation:
Your Health
1. Have you been under the care of a physician, dermatologist, or other medical professional within the past year?

NoYes
If yes, explain:
2. Any recent surgery, including plastic surgery?

NoYes
If yes, explain:
3. Any Skin Cancer?

NoYes
If yes, explain:
4. Have you had any piercings, tattoos, or permanent cosmetics?

NoYes
If yes, where on your person?
5. Have you ever had a body spa treatment before?

NoYes
If yes, when:

6. 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)

	No	Yes	If yes, describe:
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 migraines)
Hepatitis
Herpes
Frequent cold sores
Immune or Auto-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
Braces, metal fillings
Other dental implants
Current Cold or Flu
Connective Tissue Disease
Stroke/TIA
Bell's Palsy
Thrombosis or Embolism
Recent Scar Tissue
Skin Inflammation Disorders
Sensitive Skin
Open Wounds
Sensitivity to Light

7. Has your physician discussed concerns about raising your body temperature?

NoYes
If yes, explain:
8. Do you smoke?

NoYes
9. Do you follow a restricted diet?

NoYes
If yes, specify:
10. Do you follow a regular exercise program?

NoYes
11. What is your stress level?

HighMediumLow
List any medications you take regularly:
List any over the counter medications (including vitamins, herbal supplements, aspirin, etc) you take regularly:
List your daily consumption of:
Water
Caffeine
Alcohol
12 (b). Have you ever had Botox®, Juvederm®, or any other injectable?

NoYes
If yes, describe:
12 (a). Do you use Retin-A, (Tretinoin) Renova, Adapalene Hydroxyl Acid, Differin, Glycolic Acid, AHA, Salicylic Acid, or Retinol/Vitamin A derivative products?

NoYes
If yes, describe:
13. Have you used any of these products in the last 3 months?

NoYes
14. Have you used an acne medication?

NoYes
If yes, when?
Which drug?
15. Do you form thick or raised scars from cuts or burns?

NoYes
16. Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?

NoYes
If yes, describe:
17. Do you experience any problems sleeping?

NoYes
18) How many hours do you typically sleep each night?
19. Do you wear contact lenses?

NoYes
20. Have you been exposed to the sun or used a tanning bed in the last 48 hours?

NoYes
21. How frequently are you exposed to the sun or use a tanning bed?

InfrequentlyFrequentlyRegularly
22. Do you have any metal implants or wear a pacemaker?

NoYes
23. Have you ever experienced claustrophobia?

NoYes
24. Do you suffer from sinus problems?

NoYes
25. Have you ever had an adverse reaction after using any skin care product? (Please check any that apply)

RashIrritationPeelingSun SensitivityBreakoutOther
Please list the skincare products you use daily/weekly:
26. Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain below)

CosmeticsFragranceMedicineShellfishFoodLatexAnimalsDrugsSunscreensIodinePollenAlpha Hydroxy AcidsPlants/FlowersOther
If yes, please list all allergies specifically which food, drug, topical product, and/or plant:
Are you allergic or sensitive to any essential oils?
27. Are you taking oral contraceptives?

NoYes
If yes, specify:
28. Any recent changes to your contraceptive treatment?

NoYes
If so, what and when?
29. Are you pregnant or trying to become pregnant?

NoYes
30. Are you lactating?

NoYes
31. Any menopause problems?

NoYes
If yes, specify:
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. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.
Client Signature:

Clear
Parent or Guardian Signature (in case of a minor):

Clear
Date:

MonthDayYear
Should be Empty:

Your Health