Skin Care History
Name: ______Date:
Address:
City: ______State: ______Zip:
Email Address:
Cell Phone: ______Date of Birth:
Emergency Contact: ______Phone:
Are you pregnant: Yes q No q If yes, how far along:
Do you have any of the following health conditions:
Melt Massage & Facial Studio 01/2011Page 1
q AIDS/HIV
q Cancer
q Diabetes
q Heart Problems
q Hepatitis
q High/Low Blood Pressure
q Lupus
q Recent Surgeries
q Strokes
Melt Massage & Facial Studio 01/2011Page 1
Melt Massage & Facial Studio 01/2011Page 1
Please list any other health conditions not listed above:
Are you currently using any of the following?
Melt Massage & Facial Studio 01/2011Page 1
q Retin A/Renova
q Glycolic Acid/Alpha Hydroxy Acid
q Accutane
q Topical Vitamin C
q Hydroquinone
q Hormone Replacement Therapy
q Birth Control Pills
q Sunscreen/Sun Block
Melt Massage & Facial Studio 01/2011Page 1
If yes, please list the names of any prescription medication(s): _
Are you using or have ever used any medications for acne? q Yes q No
If yes, how long has it been since you last used acne medication?
Do you suffer from Cold Sores? q Yes q No If yes, do you take medication? q Yes q No
Do you smoke? q Yes q No
Do you tan? q Yes q No
Have you had facials before? q Yes q No
Have you had electrolysis, laser hair removal, or waxing in the last week? q Yes q No
What skin care products are you currently using?
Skin Care History Cont.
Have you ever had an allergic reaction to any of the following?
Melt Massage & Facial Studio 01/2011Page 1
q Cosmetics
q Medication
q Food
q Animals
q Sunscreens
q Iodine
q Pollen
q Skin Products
q Essential Oils
q Nuts
q Alpha Hydroxy Acids
q Fragrance
q Shellfish
q Latex
q Aspirin
q Other
Melt Massage & Facial Studio 01/2011Page 1
If yes to any of the above, please explain ______
______
Melt Massage & Facial Studio 01/2011Page 1
Have you had any of the following?
Melt Massage & Facial Studio 01/2011Page 1
q Cosmetic Surgery
q Botox Injections
q Skin Cancer
q Dermatitis
q Keloid Scarring
q Laser Resurfacing
q Chemical Peels
q Other ______
Melt Massage & Facial Studio 01/2011Page 1
If yes to any of the above, please state when your last treatment was:
What areas of concern do you have regarding your skin?
Melt Massage & Facial Studio 01/2011Page 1
q Breakouts/Acne
q Blackheads/Whiteheads
q Excessive Oil/Shine
q Rosacea
q Broken Capillaries
q Sun/Liver/Brown Spots
q Enlarged Pores
q Uneven Skin Tone
q Sun Damage
q Wrinkles/Fine Lines
q Dull/Dry Skin
q Flaky Skin
q Dehydrated
q Other ______
Melt Massage & Facial Studio 01/2011Page 1
Melt Massage & Facial Studio 01/2011Page 1
Is there any other information I should know before beginning your treatment?
It is your responsibility to inform Maria Keith of any pre-existing and all health conditions. It is also your responsibility to inform Maria Keith of any discomfort during any session.
I ______understand and accept any risks of which I have been advised associated with the agreed upon skin treatment. I release Maria Keith from all liability arising from any injury and/or damage from failure to inform Maria Keith of any pre-existing conditions, limitations, specific sensitivities, and/or any discomfort during the treatment. I agree to keep Maria Keith updated as to any changes in my medical profile.
Client Signature: Date: ______
Parent or Guardian: Date: ______
Melt Massage & Facial Studio 01/2011Page 1