Facial Health Form Please enable JavaScript in your browser to complete this form.1Personal Info2Your HealthHave you visited us before? *Yes, I’m a returning clientNo, I’m a new clientHas anything changed in your health since your last visit? *YesNoName *FirstLastDate of Birth *Gender *MaleFemaleAddress *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *Cell Phone *Alternate Phone NumberEmergency Contact *Emergency Contact Phone *NextHave you been under the care of a physician, dermatologist or other medical professional within the past year? *NoYesExplain *Any recent surgery, including plastic surgery?NoYesExplain *Any skin cancer? NoYesExplain *Have you had any piercings, tattoos, or permanent cosmetics?NoYesWhere on your body? *Have you ever had a body spa treatment before?NoYesWhen?Have you had any of these health conditions in the past or present? CancerHeadaches (chronic)Hormone imbalanceHepatitisSystemic diseaseHerpesHigh blood pressureFrequent cold soresSpinal injuryImmune disordersThyroid conditionHIV/AIDSHysterectomyLupusDiabetesMetal bone pins or platesHeart problemPhlebitis, blood clots, poor circulationVaricose veinsBlood clotting abnormalitiesArthritisPsychological treatmentAsthmaInsomniaEczemaKeloid scarringEpilepsySkin disease/skin lesionsSeizure disorderAny active infectionFever blisters(Please check all that apply and provide additional information in the space provided)Provide Details Has your physician discussed concerns about raising your body temperature? *NoYesExplain *Do you smoke?NoYesDo you follow a restricted diet?NoYesPlease specify *Do you follow a regular exercise program?NoYesWhat is your stress level?HighMediumLowList any medications you take regularlyList 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? NoYesPlease describe * Have you used any of these products in the last 3 months? *NoYesWhen?Which Drug?Do you form thick or raised scars from cuts or burns?NoYesDo you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?NoYesPlease describe *What is your daily water consumption?What is your daily caffeine consumption?What is your daily alcohol consumption?Do you experience any problems sleeping?NoYesHow many hours do you typically sleep each night? Do you wear contact lenses? NoYesHave you been exposed to the sun or used a tanning bed in the last 48 hours?NoYesHow frequently are you exposed to the sun or use a tanning bed?InfrequentlyFrequentlyRegularlyDo you have any metal implants or wear a pacemaker?NoYesHave you ever experienced claustrophobia?NoYesDo you suffer from sinus problems?NoYesHave you ever had an adverse reaction after using any skin care product? (Please check any that apply) RashIrritationPeelingSun SensitivityBreakoutHave you ever had an allergic reaction to any of the following? (Please check any that apply and explain)CosmeticsMedicineFoodAnimalsSunscreensIodinePollenAHAsFragranceShellfishLatexDrugsOtherPlease provide *Please explain *Are you taking oral contraceptives?NoYesPlease explain *Any recent changes to or from your contraceptive treatment?NoYesIf so, what and when? *Are you pregnant or trying to become pregnant?NoYesAre you lactating?NoYesAny menopause problems? NoYesPlease specify *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. Sign Date *Captcha * = Just so we know you’re not a bot 🙂PreviousSubmit
