CLIENT CONSULTATION & HEALTH HISTORY
Name: ______Date: ______
Street: ______
City/State: ______Zip: ______
Cell Phone # ______Email: ______
Cell Phone Provider: ______
Physician: ______Phone: ______
Emergency Contact: ______Phone: ______
YOUR HEALTH
1. Have you ever had a facial treatment before? __ No __ Yes
2. Which of the following best describes your skin type? (Please circle one type number)
I Creamy complexion Always burns easily; never tans
II Light complexion Always burns, tans slightly
III Light/Matte complexion Burns moderately, tans gradually
IV Matte complexion Seldom burns, always tans
V Brown complexion Rarely burns, deep tan
VI Black complexion Never burns, deeply pigmented
What is your hereditary background? ______
3. Do you have any special skin problems or concerns pertaining to your face or body?
__No __ Yes Specify: ______
4. Have you ever had chemical peels, laser or microdermabrasion? __No __ Yes
In the last month?__No __ Yes
5. Have you been under the care of a physician, dermatologist or other medical professional within the past year? __No __ Yes Explain: ______
6. Any recent surgery, including plastic surgery? __ No __Yes Explain:______
______
7. Any skin cancer: __ No ___ Yes Explain ______
8. Have you had any piercings, tattoos or permanent cosmetics? __ No __ Yes
If yes, where on your person? ______
9. Have you recently used any self-tanning lotions, creams or treatments? ___ No ___ Yes Specify: ______
10. Have you used any of the following hair removal methods in the past six weeks? ___ No ___ Yes Specify: ______
11. Have you used any of the following hair removal methods in the past six weeks? ___ No ___ Yes Check all that apply:
Shaving Waxing Electrolysis Plucking Tweezing Threading Depilatories
12. Have you had any of these health conditions in the past or present? Check all that apply:
___ Cancer ___ Hormone imbalance ___ Systemic disease
___ High Blood pressure ___ Spinal injury ___ Thyroid condition
___ Hysterectomy ___ Diabetes ___ Heart problem
___ Varicose veins ___ Arthritis ___ Asthma
___ Eczema ___ Epilepsy ___ Seizure disorders
___ Fever blisters ___ Headaches (chronic) ___ Hepatitis
___ Herpes ___ Frequent cold sores ___ Immune disorders
___ HIV/AIDS ___ Lupus ___ Metal bone pins or plates
___ Insomnia ___ Keloid scarring ___ Psychological treatment
___ Any active infection ___ Blood clotting abnormalities
___ Phlebitis, blood clots ___ Skin Disease/skin lesions
13. What skin care products are you currently using (list brand if known)
Soap ______Shower Gels ______
Toner ______Body Lotions ______
Mask ______Sunscreen ______
Eye Product ______SPF ______
Cleanser ______Night Moisturizer/Cream ______
Day Moisturizer ______Other ______
Exfoliator ______Makeup Products ______
14. What area of concern do you have regarding your skin? (Please check all that apply and explain: ______
Breakouts/acne _____ Uneven skin tone _____
Blackheads/whiteheads _____ Sun damage _____
Excessive oil/shine _____ Wrinkles/fine lines _____
Rosacea _____ Dull/dry skin _____
Broken capillaries _____ Flaky skin _____
Redness/ruddiness _____ Dehydrated _____
Sun spots/brown spots _____ Other ______
15. Eyes:
Dehydrated _____ Wrinkles _____ Puffiness _____ Dark circles _____ Other ______
16. Lips:
Dehydrated _____ Cracked/chapped _____ Other ______
17. Has your physician discussed concerns about raising your body temperature? __No __ Yes
Explain:
18. Do you smoke: ___No ___ Yes
19. Do you follow a restricted diet? ___ No ___ Yes Specify: ______
20. Do you follow a regular exercise program? ___No ___ Yes
21. What is your stress level? ___ High ___ Medium ___ Low
22. List any medications you take regularly: ______
______
23. Do you use Retin-A. Renova, Adapalene Hydroxyl Acid, Deterin, Glycolic Acid, AHA, Salicylic Acid or Retinol/Vitamin A derivative products? __ No __ Yes Describe: ______
______
24. Have you used any of these products in the last 3 months? ___ No ___ Yes
25. Have you used an acne medication? __ No __ Yes When? ______Which drug? ______
26. Do you form thick or raised scars from cuts or burns? __ No ___ Yes
27. Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma? ___ No ___ Yes
28. List your daily consumption of: Water______Caffeine ______Alcohol______
29. Do you wear contact lenses? ___ No ___ Yes
30. Have you been exposed to the sun or used a tanning bed in the last 48 hours? ___ No ___Yes
31. How frequently are you exposed to the sun or use a tanning bed? ___ Infrequently ___ Frequently ___ Regularly
32. Do you have any metal implants or wear a pacemaker? ___ No ___ Yes
33. Have you ever experienced claustrophobia? ___ No ___ Yes
34. Do you suffer from sinus problems? ___ No ___ Yes
35. Have you ever had an adverse reaction after using any skin care product? (Please circle all that apply)
Rash Irritation Peeling Sun Sensitivity Breakout
36. Have you ever had an allergic reaction to any of the following? (Please circle any that apply and explain)
Cosmetics Medications Food Animals Sunscreens Iodine Pollen AHAs Aspirin
Fragrances Shellfish Latex Drugs ______Other ______
If yes, please explain:______
FEMALE CLIENTS ONLY
37. Are you taking contraceptives? ___ No ___ Yes Specify: ______
38. Any recent changes to or from your contraceptive treatment? ___ No ___ Yes
Specify: ______
39. Are you pregnant or trying to become pregnant? ___ No ___ Yes
40. Are you lactating? ___ No ___ Yes
41. Any menopause problems? ___ No ___ Yes Specify:
MALE CLIENTS ONLY
42. What is your current shaving system? ___ Wet Shave ___ Electric
43. Do you experience irritation from shaving? ___ No ___ Yes Ingrown Hairs: ? ___ No ___ Yes
Please use this space to complete answers where space was insufficient (include # of question)
______
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure and that is 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.
______Date ______
Client Signature