Confidential Client Health History Form
Date:________________________________
Name:___________________________________________________________________ Date Of Birth:___________
Address:_________________________________________________________________________________________
Home Phone:___________________________________ Business Phone:___________________________________
Cell Phone:______________________________________________ E-mail:___________________________________
Physician:_______________________________________________Phone:___________________________________
Emergency Contact:______________________________________Phone:___________________________________
Your Health
1) Have you been under the care of a physician, dermatologist or other medical professional within the past year?
m No m Yes, explain:_____________________________________________________________________________
2) Any recent surgery, including plastic surgery? m No m Yes, explain:____________________________________
________________________________________________________________________________________________
3) Any skin cancer? m No m Yes, explain:_____________________________________________________________
4) Have you had any piercings, tattoos, or permanent cosmetics? m No m Yes, If yes, where on your person?
_______________________________________________________________________________________________
_____________________________________________________________
5) Have you ever had a body spa treatment before? m No m 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)
Cancer o Headaches (chronic) o
Hormone imbalance o Hepatitis o
Systemic disease o Herpes o
High blood pressure o Frequent cold sores o
Spinal injury o Immune disorders o
Thyroid condition o HIV/AIDS o
Hysterectomy o Lupus o
Diabetes o Metal bone pins or plates o
Heart problem o Phlebitis, blood clots, poor circulation o
Varicose veins o Blood clotting abnormalities o
Arthritis o Psychological treatment o
Asthma o Insomnia o
Eczema o Keloid scarring o
Epilepsy o Skin disease/skin lesions o
Seizure disorder o Any active infection o
Fever blisters o
7) Has your physician discussed concerns about raising your body temperature? m No m Yes
explain:_______________________________________________________________________________________
________________________________________________________________________________________________
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Confidential Client Health History Form—continued
8) Do you smoke? m No m Yes
9) Do you follow a restricted diet? m No m Yes, specify:_________________________________________________
10) Do you follow a regular exercise program? m No m Yes
11) What is your stress level? High o Medium o Low o
List any medications you take regularly:______________________________________________________________
List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:
________________________________________________________________________________________________
12) D
o you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or
Retinol/vitamin A derivative products? m No m Yes, describe:________________________________________
13) Have you used any of these products in the last 3 months? m No m Yes
14) Have you used an acne medication? m No m Yes, when? ___________ Which drug?___________________
15) Do you form thick or raised scars from cuts or burns? m No m Yes
16) D
o you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or
marks after physical trauma? m No m Yes, describe:_______________________________________________
List your daily consumption of: Water ______________ Caffeine ______________ Alcohol ______________
17) Do you experience any problems sleeping? m No m Yes
18) How many hours do you typically sleep each night? __________
19) Do you wear contact lenses? m No m Yes
20) Have you been exposed to the sun or used a tanning bed in the last 48 hours? m No m Yes
21) How frequently are you exposed to the sun or use a tanning bed? ___Infrequently ___Frequently ___Regularly
22) Do you have any metal implants or wear a pacemaker? m No m Yes
23) Have you ever experienced claustrophobia? m No m Yes
24) Do you suffer from sinus problems? m No m Yes
25) Have you ever had an adverse reaction after using any skin care product? (Please circle any that apply)
Rash Irritation Peeling Sun Sensitivity Breakout
26) Have you ever had an allergic reaction to any of the following? (Please circle any that apply and explain)
Cosmetics Medicine Food Animals Sunscreens Iodine Pollen AHAs
Fragrance Shellfish Latex Drugs Other: ________________
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member
Associated Skin Care Professionals
Confidential Client Health History Form—continued
If yes, please explain:______________________________________________________________________________
Female Clients Only:
27) Are you taking oral contraceptives? m No m Yes, specify:____________________________________________
28) Any recent changes to or from your contraceptive treatment? m No m Yes, If so, what and when?____________
_____________________________________________________________
________________________________________________________________________________________________
29) Are you pregnant or trying to become pregnant? m No m Yes
30) Are you lactating? m No m Yes
31) Any menopause problems? m No m Yes, specify:__________________________________________________
Please use this space to complete answers where space was insufficient. (Please include the number of the question)
________________________________________________________________________________________________
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________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
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: _____________________________________________________________ Date:______________
member
Associated Skin Care Professionals
