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New Client Treatment/Health History Form

We want to give you the best treatment possible with results your sure to love.

Please fill out the form completely and preferrably in advance before your scheduled appointment. 

If something does not apply to you, please indacate with a "N/A" in the available space box provided.

We look forward to seeing you :)

I hereby consent to and authorize Raylene Davis on behalf of Beauty and the Blend By Raylene to perform treatment/treatments.

I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of this treatment has been explained to me, along with the risks and hazards involved, by Raylene Davis.

Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost.

I have read and understand the post-treatment home care instructions. I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult Raylene Davis immediately.

I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs, vitamins/supplements or products I am currently ingesting or using topically.

I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold Raylene Davis the esthetician or Beauty and the Blend by Raylene, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment/s performed today.

 

Rescheduling/Cancellation Policy

We understand that unanticipated events happen occasionally in everyone’s life. In our desire to be effective and fair to all clients, the following policies are honored:

ARRIVAL TIME
Please aim to arrive 10 minutes before scheduled appointment time.  If a client arrives after their scheduled appointment time; Depending upon how late a client arrives, we will then determine if there is enough time remaining to start treatment. If treatment is shortened due to client's late arrival, client will still be charged the full cost of the treatment. Out of respect and consideration to us and other customers, please plan accordingly.

RESCHEDULE/CANCEL
24 hour notice is required to reschedule or cancel a booked appointment, This allows the opportunity for someone else to schedule an appointment. If clients are unable to give us 24 hours advance notice, they may be charged the full amount of their appointment at our discretion. This amount will be paid with the card on file and/or prior to their next scheduled appointment. Exception in cases of infectious or illness as described below:

ILLNESS
If you, or another person in your household, has an infectious or contagious illness, please contact us as soon as possible to reschedule your appointment for a later date. There is no penalty in this case, for your safety and that of our other clients.

NO-SHOW

Clients who either forgets or consciously chooses to forgo their appointment for whatever reason will be considered a “no-show.” They will be charged the full amount for their “missed” appointment paid with the card on file and/or prior to their next scheduled appointment.

I agree to the policies described above.

 

Today's Date: October 20, 2019

 

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information
Single:*
No
Yes
Married:*
No
Yes

If yes, anniversary date:

Employer:

Occupation:
Does your job require that you work outdoors?*
No
Yes

We love referrals! How/who were you referred by:

What would you like to achieve from your treatment today?
1) Have you ever had a facial treatment before?*
No
Yes

Yes, when?
2) Have you ever had a body spa treatment before?*
No
Yes

Yes, when?
Massage:*
No
Yes
Salt glow:*
No
Yes
Seaweed wrap:*
No
Yes
Moor mud:*
No
Yes
Body scrub:*
No
Yes

Other:
3) Which of the following best describes your skin type?*
4) Do you have any special skin problems or concerns pertaining to your face or body?*
No
Yes

Specify:
5) Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes
In the last month?*
No
Yes
6) Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes

Describe:
7) Have you used any of these products in the last 3 months?*
No
Yes
8) Have you used an acne medication?*
No
Yes

Yes, when?

Which drug?

Soap

Toner

Mask

Eye Product

Cleanser

Day Moisturizer

Exfoliator

Scrubs

Shower Gels

Body Lotions

Sunscreen

SPF

Night Moisturizer/Cream

Other

Makeup Products

9) What skin care products are you currently using? (List brand where known)
10) Have you recently used any self-tanning lotions, creams or treatments?*
No
Yes

Yes, specify:
11) Have you used any of the following hair removal methods in the past six weeks?*
No
Yes
Yes, check all that apply.
Shaving
Waxing
Electrolysis
Tweezing
Stringing
Depilatories
12) What areas of concern do you have regarding your Skin:
Breakouts/acne
Blackheads/whiteheads
Excessive oil/shine
Rosacea
Broken capillaries
Redness/ruddiness
Sun spot/liver spot/brown spot
Uneven skin tone
Sun damage
Wrinkles/fine lines
Dull/dry skin
Flaky skin
Dehydrated
Other

If Other:
What areas of concern do you have regarding your Eyes:
dehydrated
wrinkles
puffiness
dark circles
Other

If Other:
What areas of concern do you have regarding your Lips:
dehydrated
cracked/chapped lips
Other

If Other:
13) Have you ever had an allergic reaction to any of the following? (Please check any that apply)
Cosmetics
Medicine
Food
Animals
Sunscreens
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex
Drugs
Other

Please explain:

14) What SPF do you use on your face?

How often/when?

15) What SPF do you use on your body?

How often/when?
16) Have you had any recent tanning bed or sun exposure that changed the color of your skin?*
No
Yes

Specify:
17) Have you received Botox, Restylane or Collagen injections?*
No
Yes

If so, what and when:

Female Clients Only: 

18) Are you taking oral contraceptives?*
No
Yes

If so, what and when:
20) Are you pregnant or trying to become pregnant?*
No
Yes
21) Are you lactating?*
No
Yes
22) Any menopause problems?*
No
Yes

Specify:
23) Are you undergoing any hormone replacement therapy?*
No
Yes

Specify:

Male Clients Only: 

24) What is your current shaving system?
Wet Shave
Electric
25) Do you experience irritation from shaving?*
No
Yes
Ingrown hairs?*
No
Yes

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

Future Appointments/Contact: 

May I call/text you at your home, work or cell phone number you provided to confirm future appointments?*
No
Yes
May I contact you via text/mail/email about future monthly specials, new treatments, and news?*
No
Yes

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previ- ous 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. The treatments I receive here are voluntary and I release this institution and/or skin care profes- sional from liability and assume full responsibility thereof. 

HEALTH HISTORY


Physician:

Phone:
1) Have you been under the care of a physician, dermatologist or other medical professional within the past year?*
No
Yes

Yes, explain:
2) Any recent surgery, including plastic surgery?*
No
Yes

Yes, explain:
3) Any skin cancer?*
No
Yes

Yes, explain:
4) Have you had any piercings, tattoos, or permanent cosmetics?*
No
Yes

If yes, where on your person?
5) Have you ever had a body spa treatment before?*
No
Yes

Yes, when?
6) Have you had any of these health conditions in the past or present?
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)
Hepatitis
Herpes
Frequent cold sores
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
7) Has your physician discussed concerns about raising your body temperature?*
No
Yes

Yes, explain:
8) Do you smoke?*
No
Yes
9) Do you follow a restricted diet?*
No
Yes

Yes, specify:
10) Do you follow a regular exercise program?*
No
Yes
11) What is your stress level?*

List any medications you take regularly:

List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:
12) Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?*
No
Yes

Yes, explain:
13) Have you used any of these products in the last 3 months?*
No
Yes
14) Have you used an acne medication?*
No
Yes

Yes, when?

Which drug?
15) Do you form thick or raised scars from cuts or burns?*
No
Yes
16) Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
No
Yes

Yes, describe:

List your daily consumption of Water:

List your daily consumption of Caffeine:

List your daily consumption of Alcohol:
17) Do you experience any problems sleeping?*
No
Yes

18) How many hours do you typically sleep each night?
19) Do you wear contact lenses?*
No
Yes
20) Have you been exposed to the sun or used a tanning bed in the last 48 hours?*
No
Yes
21) How frequently are you exposed to the sun or use a tanning bed?*
22) Do you have any metal implants or wear a pacemaker?*
No
Yes
23) Have you ever experienced claustrophobia?*
No
Yes
24) Do you suffer from sinus problems?*
No
Yes
25) Have you ever had an adverse reaction after using any skin care product? (Please check any that apply)
Rash
Irritation
Peeling
Sun Senstitivity
Breakout
26) Have you ever had an allergic reaction to any of the following? (Please circle any that apply)
Cosmetics
Medicine
Food
Animals
Sunscreens
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex Drugs
Other

If Other:

If yes, please explain:

Female Clients Only

27) Are you taking oral contraceptives?*
No
Yes

Yes, specify:
28) Any recent changes to or from your contraceptive treatment?*
No
Yes

If so, what and when?
29) Are you pregnant or trying to become pregnant?*
No
Yes
30) Are you lactating?*
No
Yes
31) Any menopause problems?*
No
Yes

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. 

First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information
Single:*
No
Yes
Married:*
No
Yes

If yes, anniversary date:

Employer:

Occupation:
Does your job require that you work outdoors?*
No
Yes

We love referrals! How/who were you referred by:

What would you like to achieve from your treatment today?
1) Have you ever had a facial treatment before?*
No
Yes

Yes, when?
2) Have you ever had a body spa treatment before?*
No
Yes

Yes, when?
Massage:*
No
Yes
Salt glow:*
No
Yes
Seaweed wrap:*
No
Yes
Moor mud:*
No
Yes
Body scrub:*
No
Yes

Other:
3) Which of the following best describes your skin type?*
4) Do you have any special skin problems or concerns pertaining to your face or body?*
No
Yes

Specify:
5) Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes
In the last month?*
No
Yes
6) Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes

Describe:
7) Have you used any of these products in the last 3 months?*
No
Yes
8) Have you used an acne medication?*
No
Yes

Yes, when?

Which drug?

Soap

Toner

Mask

Eye Product

Cleanser

Day Moisturizer

Exfoliator

Scrubs

Shower Gels

Body Lotions

Sunscreen

SPF

Night Moisturizer/Cream

Other

Makeup Products

9) What skin care products are you currently using? (List brand where known)
10) Have you recently used any self-tanning lotions, creams or treatments?*
No
Yes

Yes, specify:
11) Have you used any of the following hair removal methods in the past six weeks?*
No
Yes
Yes, check all that apply.
Shaving
Waxing
Electrolysis
Tweezing
Stringing
Depilatories
12) What areas of concern do you have regarding your Skin:
Breakouts/acne
Blackheads/whiteheads
Excessive oil/shine
Rosacea
Broken capillaries
Redness/ruddiness
Sun spot/liver spot/brown spot
Uneven skin tone
Sun damage
Wrinkles/fine lines
Dull/dry skin
Flaky skin
Dehydrated
Other

If Other:
What areas of concern do you have regarding your Eyes:
dehydrated
wrinkles
puffiness
dark circles
Other

If Other:
What areas of concern do you have regarding your Lips:
dehydrated
cracked/chapped lips
Other

If Other:
13) Have you ever had an allergic reaction to any of the following? (Please check any that apply)
Cosmetics
Medicine
Food
Animals
Sunscreens
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex
Drugs
Other

Please explain:

14) What SPF do you use on your face?

How often/when?

15) What SPF do you use on your body?

How often/when?
16) Have you had any recent tanning bed or sun exposure that changed the color of your skin?*
No
Yes

Specify:
17) Have you received Botox, Restylane or Collagen injections?*
No
Yes

If so, what and when:

Female Clients Only: 

18) Are you taking oral contraceptives?*
No
Yes

If so, what and when:
20) Are you pregnant or trying to become pregnant?*
No
Yes
21) Are you lactating?*
No
Yes
22) Any menopause problems?*
No
Yes

Specify:
23) Are you undergoing any hormone replacement therapy?*
No
Yes

Specify:

Male Clients Only: 

24) What is your current shaving system?
Wet Shave
Electric
25) Do you experience irritation from shaving?*
No
Yes
Ingrown hairs?*
No
Yes

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

Future Appointments/Contact: 

May I call/text you at your home, work or cell phone number you provided to confirm future appointments?*
No
Yes
May I contact you via text/mail/email about future monthly specials, new treatments, and news?*
No
Yes

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previ- ous 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. The treatments I receive here are voluntary and I release this institution and/or skin care profes- sional from liability and assume full responsibility thereof. 

HEALTH HISTORY


Physician:

Phone:
1) Have you been under the care of a physician, dermatologist or other medical professional within the past year?*
No
Yes

Yes, explain:
2) Any recent surgery, including plastic surgery?*
No
Yes

Yes, explain:
3) Any skin cancer?*
No
Yes

Yes, explain:
4) Have you had any piercings, tattoos, or permanent cosmetics?*
No
Yes

If yes, where on your person?
5) Have you ever had a body spa treatment before?*
No
Yes

Yes, when?
6) Have you had any of these health conditions in the past or present?
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)
Hepatitis
Herpes
Frequent cold sores
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
7) Has your physician discussed concerns about raising your body temperature?*
No
Yes

Yes, explain:
8) Do you smoke?*
No
Yes
9) Do you follow a restricted diet?*
No
Yes

Yes, specify:
10) Do you follow a regular exercise program?*
No
Yes
11) What is your stress level?*

List any medications you take regularly:

List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:
12) Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?*
No
Yes

Yes, explain:
13) Have you used any of these products in the last 3 months?*
No
Yes
14) Have you used an acne medication?*
No
Yes

Yes, when?

Which drug?
15) Do you form thick or raised scars from cuts or burns?*
No
Yes
16) Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
No
Yes

Yes, describe:

List your daily consumption of Water:

List your daily consumption of Caffeine:

List your daily consumption of Alcohol:
17) Do you experience any problems sleeping?*
No
Yes

18) How many hours do you typically sleep each night?
19) Do you wear contact lenses?*
No
Yes
20) Have you been exposed to the sun or used a tanning bed in the last 48 hours?*
No
Yes
21) How frequently are you exposed to the sun or use a tanning bed?*
22) Do you have any metal implants or wear a pacemaker?*
No
Yes
23) Have you ever experienced claustrophobia?*
No
Yes
24) Do you suffer from sinus problems?*
No
Yes
25) Have you ever had an adverse reaction after using any skin care product? (Please check any that apply)
Rash
Irritation
Peeling
Sun Senstitivity
Breakout
26) Have you ever had an allergic reaction to any of the following? (Please circle any that apply)
Cosmetics
Medicine
Food
Animals
Sunscreens
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex Drugs
Other

If Other:

If yes, please explain:

Female Clients Only

27) Are you taking oral contraceptives?*
No
Yes

Yes, specify:
28) Any recent changes to or from your contraceptive treatment?*
No
Yes

If so, what and when?
29) Are you pregnant or trying to become pregnant?*
No
Yes
30) Are you lactating?*
No
Yes
31) Any menopause problems?*
No
Yes

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. 

Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information
Single:*
No
Yes
Married:*
No
Yes

If yes, anniversary date:

Employer:

Occupation:
Does your job require that you work outdoors?*
No
Yes

We love referrals! How/who were you referred by:

What would you like to achieve from your treatment today?
1) Have you ever had a facial treatment before?*
No
Yes

Yes, when?
2) Have you ever had a body spa treatment before?*
No
Yes

Yes, when?
Massage:*
No
Yes
Salt glow:*
No
Yes
Seaweed wrap:*
No
Yes
Moor mud:*
No
Yes
Body scrub:*
No
Yes

Other:
3) Which of the following best describes your skin type?*
4) Do you have any special skin problems or concerns pertaining to your face or body?*
No
Yes

Specify:
5) Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes
In the last month?*
No
Yes
6) Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes

Describe:
7) Have you used any of these products in the last 3 months?*
No
Yes
8) Have you used an acne medication?*
No
Yes

Yes, when?

Which drug?

Soap

Toner

Mask

Eye Product

Cleanser

Day Moisturizer

Exfoliator

Scrubs

Shower Gels

Body Lotions

Sunscreen

SPF

Night Moisturizer/Cream

Other

Makeup Products

9) What skin care products are you currently using? (List brand where known)
10) Have you recently used any self-tanning lotions, creams or treatments?*
No
Yes

Yes, specify:
11) Have you used any of the following hair removal methods in the past six weeks?*
No
Yes
Yes, check all that apply.
Shaving
Waxing
Electrolysis
Tweezing
Stringing
Depilatories
12) What areas of concern do you have regarding your Skin:
Breakouts/acne
Blackheads/whiteheads
Excessive oil/shine
Rosacea
Broken capillaries
Redness/ruddiness
Sun spot/liver spot/brown spot
Uneven skin tone
Sun damage
Wrinkles/fine lines
Dull/dry skin
Flaky skin
Dehydrated
Other

If Other:
What areas of concern do you have regarding your Eyes:
dehydrated
wrinkles
puffiness
dark circles
Other

If Other:
What areas of concern do you have regarding your Lips:
dehydrated
cracked/chapped lips
Other

If Other:
13) Have you ever had an allergic reaction to any of the following? (Please check any that apply)
Cosmetics
Medicine
Food
Animals
Sunscreens
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex
Drugs
Other

Please explain:

14) What SPF do you use on your face?

How often/when?

15) What SPF do you use on your body?

How often/when?
16) Have you had any recent tanning bed or sun exposure that changed the color of your skin?*
No
Yes

Specify:
17) Have you received Botox, Restylane or Collagen injections?*
No
Yes

If so, what and when:

Female Clients Only: 

18) Are you taking oral contraceptives?*
No
Yes

If so, what and when:
20) Are you pregnant or trying to become pregnant?*
No
Yes
21) Are you lactating?*
No
Yes
22) Any menopause problems?*
No
Yes

Specify:
23) Are you undergoing any hormone replacement therapy?*
No
Yes

Specify:

Male Clients Only: 

24) What is your current shaving system?
Wet Shave
Electric
25) Do you experience irritation from shaving?*
No
Yes
Ingrown hairs?*
No
Yes

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

Future Appointments/Contact: 

May I call/text you at your home, work or cell phone number you provided to confirm future appointments?*
No
Yes
May I contact you via text/mail/email about future monthly specials, new treatments, and news?*
No
Yes

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previ- ous 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. The treatments I receive here are voluntary and I release this institution and/or skin care profes- sional from liability and assume full responsibility thereof. 

HEALTH HISTORY


Physician:

Phone:
1) Have you been under the care of a physician, dermatologist or other medical professional within the past year?*
No
Yes

Yes, explain:
2) Any recent surgery, including plastic surgery?*
No
Yes

Yes, explain:
3) Any skin cancer?*
No
Yes

Yes, explain:
4) Have you had any piercings, tattoos, or permanent cosmetics?*
No
Yes

If yes, where on your person?
5) Have you ever had a body spa treatment before?*
No
Yes

Yes, when?
6) Have you had any of these health conditions in the past or present?
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)
Hepatitis
Herpes
Frequent cold sores
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
7) Has your physician discussed concerns about raising your body temperature?*
No
Yes

Yes, explain:
8) Do you smoke?*
No
Yes
9) Do you follow a restricted diet?*
No
Yes

Yes, specify:
10) Do you follow a regular exercise program?*
No
Yes
11) What is your stress level?*

List any medications you take regularly:

List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:
12) Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?*
No
Yes

Yes, explain:
13) Have you used any of these products in the last 3 months?*
No
Yes
14) Have you used an acne medication?*
No
Yes

Yes, when?

Which drug?
15) Do you form thick or raised scars from cuts or burns?*
No
Yes
16) Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
No
Yes

Yes, describe:

List your daily consumption of Water:

List your daily consumption of Caffeine:

List your daily consumption of Alcohol:
17) Do you experience any problems sleeping?*
No
Yes

18) How many hours do you typically sleep each night?
19) Do you wear contact lenses?*
No
Yes
20) Have you been exposed to the sun or used a tanning bed in the last 48 hours?*
No
Yes
21) How frequently are you exposed to the sun or use a tanning bed?*
22) Do you have any metal implants or wear a pacemaker?*
No
Yes
23) Have you ever experienced claustrophobia?*
No
Yes
24) Do you suffer from sinus problems?*
No
Yes
25) Have you ever had an adverse reaction after using any skin care product? (Please check any that apply)
Rash
Irritation
Peeling
Sun Senstitivity
Breakout
26) Have you ever had an allergic reaction to any of the following? (Please circle any that apply)
Cosmetics
Medicine
Food
Animals
Sunscreens
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex Drugs
Other

If Other:

If yes, please explain:

Female Clients Only

27) Are you taking oral contraceptives?*
No
Yes

Yes, specify:
28) Any recent changes to or from your contraceptive treatment?*
No
Yes

If so, what and when?
29) Are you pregnant or trying to become pregnant?*
No
Yes
30) Are you lactating?*
No
Yes
31) Any menopause problems?*
No
Yes

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. 

Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information
Single:*
No
Yes
Married:*
No
Yes

If yes, anniversary date:

Employer:

Occupation:
Does your job require that you work outdoors?*
No
Yes

We love referrals! How/who were you referred by:

What would you like to achieve from your treatment today?
1) Have you ever had a facial treatment before?*
No
Yes

Yes, when?
2) Have you ever had a body spa treatment before?*
No
Yes

Yes, when?
Massage:*
No
Yes
Salt glow:*
No
Yes
Seaweed wrap:*
No
Yes
Moor mud:*
No
Yes
Body scrub:*
No
Yes

Other:
3) Which of the following best describes your skin type?*
4) Do you have any special skin problems or concerns pertaining to your face or body?*
No
Yes

Specify:
5) Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes
In the last month?*
No
Yes
6) Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes

Describe:
7) Have you used any of these products in the last 3 months?*
No
Yes
8) Have you used an acne medication?*
No
Yes

Yes, when?

Which drug?

Soap

Toner

Mask

Eye Product

Cleanser

Day Moisturizer

Exfoliator

Scrubs

Shower Gels

Body Lotions

Sunscreen

SPF

Night Moisturizer/Cream

Other

Makeup Products

9) What skin care products are you currently using? (List brand where known)
10) Have you recently used any self-tanning lotions, creams or treatments?*
No
Yes

Yes, specify:
11) Have you used any of the following hair removal methods in the past six weeks?*
No
Yes
Yes, check all that apply.
Shaving
Waxing
Electrolysis
Tweezing
Stringing
Depilatories
12) What areas of concern do you have regarding your Skin:
Breakouts/acne
Blackheads/whiteheads
Excessive oil/shine
Rosacea
Broken capillaries
Redness/ruddiness
Sun spot/liver spot/brown spot
Uneven skin tone
Sun damage
Wrinkles/fine lines
Dull/dry skin
Flaky skin
Dehydrated
Other

If Other:
What areas of concern do you have regarding your Eyes:
dehydrated
wrinkles
puffiness
dark circles
Other

If Other:
What areas of concern do you have regarding your Lips:
dehydrated
cracked/chapped lips
Other

If Other:
13) Have you ever had an allergic reaction to any of the following? (Please check any that apply)
Cosmetics
Medicine
Food
Animals
Sunscreens
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex
Drugs
Other

Please explain:

14) What SPF do you use on your face?

How often/when?

15) What SPF do you use on your body?

How often/when?
16) Have you had any recent tanning bed or sun exposure that changed the color of your skin?*
No
Yes

Specify:
17) Have you received Botox, Restylane or Collagen injections?*
No
Yes

If so, what and when:

Female Clients Only: 

18) Are you taking oral contraceptives?*
No
Yes

If so, what and when:
20) Are you pregnant or trying to become pregnant?*
No
Yes
21) Are you lactating?*
No
Yes
22) Any menopause problems?*
No
Yes

Specify:
23) Are you undergoing any hormone replacement therapy?*
No
Yes

Specify:

Male Clients Only: 

24) What is your current shaving system?
Wet Shave
Electric
25) Do you experience irritation from shaving?*
No
Yes
Ingrown hairs?*
No
Yes

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

Future Appointments/Contact: 

May I call/text you at your home, work or cell phone number you provided to confirm future appointments?*
No
Yes
May I contact you via text/mail/email about future monthly specials, new treatments, and news?*
No
Yes

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previ- ous 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. The treatments I receive here are voluntary and I release this institution and/or skin care profes- sional from liability and assume full responsibility thereof. 

HEALTH HISTORY


Physician:

Phone:
1) Have you been under the care of a physician, dermatologist or other medical professional within the past year?*
No
Yes

Yes, explain:
2) Any recent surgery, including plastic surgery?*
No
Yes

Yes, explain:
3) Any skin cancer?*
No
Yes

Yes, explain:
4) Have you had any piercings, tattoos, or permanent cosmetics?*
No
Yes

If yes, where on your person?
5) Have you ever had a body spa treatment before?*
No
Yes

Yes, when?
6) Have you had any of these health conditions in the past or present?
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)
Hepatitis
Herpes
Frequent cold sores
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
7) Has your physician discussed concerns about raising your body temperature?*
No
Yes

Yes, explain:
8) Do you smoke?*
No
Yes
9) Do you follow a restricted diet?*
No
Yes

Yes, specify:
10) Do you follow a regular exercise program?*
No
Yes
11) What is your stress level?*

List any medications you take regularly:

List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:
12) Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?*
No
Yes

Yes, explain:
13) Have you used any of these products in the last 3 months?*
No
Yes
14) Have you used an acne medication?*
No
Yes

Yes, when?

Which drug?
15) Do you form thick or raised scars from cuts or burns?*
No
Yes
16) Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
No
Yes

Yes, describe:

List your daily consumption of Water:

List your daily consumption of Caffeine:

List your daily consumption of Alcohol:
17) Do you experience any problems sleeping?*
No
Yes

18) How many hours do you typically sleep each night?
19) Do you wear contact lenses?*
No
Yes
20) Have you been exposed to the sun or used a tanning bed in the last 48 hours?*
No
Yes
21) How frequently are you exposed to the sun or use a tanning bed?*
22) Do you have any metal implants or wear a pacemaker?*
No
Yes
23) Have you ever experienced claustrophobia?*
No
Yes
24) Do you suffer from sinus problems?*
No
Yes
25) Have you ever had an adverse reaction after using any skin care product? (Please check any that apply)
Rash
Irritation
Peeling
Sun Senstitivity
Breakout
26) Have you ever had an allergic reaction to any of the following? (Please circle any that apply)
Cosmetics
Medicine
Food
Animals
Sunscreens
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex Drugs
Other

If Other:

If yes, please explain:

Female Clients Only

27) Are you taking oral contraceptives?*
No
Yes

Yes, specify:
28) Any recent changes to or from your contraceptive treatment?*
No
Yes

If so, what and when?
29) Are you pregnant or trying to become pregnant?*
No
Yes
30) Are you lactating?*
No
Yes
31) Any menopause problems?*
No
Yes

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. 

Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information
Single:*
No
Yes
Married:*
No
Yes

If yes, anniversary date:

Employer:

Occupation:
Does your job require that you work outdoors?*
No
Yes

We love referrals! How/who were you referred by:

What would you like to achieve from your treatment today?
1) Have you ever had a facial treatment before?*
No
Yes

Yes, when?
2) Have you ever had a body spa treatment before?*
No
Yes

Yes, when?
Massage:*
No
Yes
Salt glow:*
No
Yes
Seaweed wrap:*
No
Yes
Moor mud:*
No
Yes
Body scrub:*
No
Yes

Other:
3) Which of the following best describes your skin type?*
4) Do you have any special skin problems or concerns pertaining to your face or body?*
No
Yes

Specify:
5) Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes
In the last month?*
No
Yes
6) Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes

Describe:
7) Have you used any of these products in the last 3 months?*
No
Yes
8) Have you used an acne medication?*
No
Yes

Yes, when?

Which drug?

Soap

Toner

Mask

Eye Product

Cleanser

Day Moisturizer

Exfoliator

Scrubs

Shower Gels

Body Lotions

Sunscreen

SPF

Night Moisturizer/Cream

Other

Makeup Products

9) What skin care products are you currently using? (List brand where known)
10) Have you recently used any self-tanning lotions, creams or treatments?*
No
Yes

Yes, specify:
11) Have you used any of the following hair removal methods in the past six weeks?*
No
Yes
Yes, check all that apply.
Shaving
Waxing
Electrolysis
Tweezing
Stringing
Depilatories
12) What areas of concern do you have regarding your Skin:
Breakouts/acne
Blackheads/whiteheads
Excessive oil/shine
Rosacea
Broken capillaries
Redness/ruddiness
Sun spot/liver spot/brown spot
Uneven skin tone
Sun damage
Wrinkles/fine lines
Dull/dry skin
Flaky skin
Dehydrated
Other

If Other:
What areas of concern do you have regarding your Eyes:
dehydrated
wrinkles
puffiness
dark circles
Other

If Other:
What areas of concern do you have regarding your Lips:
dehydrated
cracked/chapped lips
Other

If Other:
13) Have you ever had an allergic reaction to any of the following? (Please check any that apply)
Cosmetics
Medicine
Food
Animals
Sunscreens
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex
Drugs
Other

Please explain:

14) What SPF do you use on your face?

How often/when?

15) What SPF do you use on your body?

How often/when?
16) Have you had any recent tanning bed or sun exposure that changed the color of your skin?*
No
Yes

Specify:
17) Have you received Botox, Restylane or Collagen injections?*
No
Yes

If so, what and when:

Female Clients Only: 

18) Are you taking oral contraceptives?*
No
Yes

If so, what and when:
20) Are you pregnant or trying to become pregnant?*
No
Yes
21) Are you lactating?*
No
Yes
22) Any menopause problems?*
No
Yes

Specify:
23) Are you undergoing any hormone replacement therapy?*
No
Yes

Specify:

Male Clients Only: 

24) What is your current shaving system?
Wet Shave
Electric
25) Do you experience irritation from shaving?*
No
Yes
Ingrown hairs?*
No
Yes

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

Future Appointments/Contact: 

May I call/text you at your home, work or cell phone number you provided to confirm future appointments?*
No
Yes
May I contact you via text/mail/email about future monthly specials, new treatments, and news?*
No
Yes

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previ- ous 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. The treatments I receive here are voluntary and I release this institution and/or skin care profes- sional from liability and assume full responsibility thereof. 

HEALTH HISTORY


Physician:

Phone:
1) Have you been under the care of a physician, dermatologist or other medical professional within the past year?*
No
Yes

Yes, explain:
2) Any recent surgery, including plastic surgery?*
No
Yes

Yes, explain:
3) Any skin cancer?*
No
Yes

Yes, explain:
4) Have you had any piercings, tattoos, or permanent cosmetics?*
No
Yes

If yes, where on your person?
5) Have you ever had a body spa treatment before?*
No
Yes

Yes, when?
6) Have you had any of these health conditions in the past or present?
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)
Hepatitis
Herpes
Frequent cold sores
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
7) Has your physician discussed concerns about raising your body temperature?*
No
Yes

Yes, explain:
8) Do you smoke?*
No
Yes
9) Do you follow a restricted diet?*
No
Yes

Yes, specify:
10) Do you follow a regular exercise program?*
No
Yes
11) What is your stress level?*

List any medications you take regularly:

List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:
12) Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?*
No
Yes

Yes, explain:
13) Have you used any of these products in the last 3 months?*
No
Yes
14) Have you used an acne medication?*
No
Yes

Yes, when?

Which drug?
15) Do you form thick or raised scars from cuts or burns?*
No
Yes
16) Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
No
Yes

Yes, describe:

List your daily consumption of Water:

List your daily consumption of Caffeine:

List your daily consumption of Alcohol:
17) Do you experience any problems sleeping?*
No
Yes

18) How many hours do you typically sleep each night?
19) Do you wear contact lenses?*
No
Yes
20) Have you been exposed to the sun or used a tanning bed in the last 48 hours?*
No
Yes
21) How frequently are you exposed to the sun or use a tanning bed?*
22) Do you have any metal implants or wear a pacemaker?*
No
Yes
23) Have you ever experienced claustrophobia?*
No
Yes
24) Do you suffer from sinus problems?*
No
Yes
25) Have you ever had an adverse reaction after using any skin care product? (Please check any that apply)
Rash
Irritation
Peeling
Sun Senstitivity
Breakout
26) Have you ever had an allergic reaction to any of the following? (Please circle any that apply)
Cosmetics
Medicine
Food
Animals
Sunscreens
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex Drugs
Other

If Other:

If yes, please explain:

Female Clients Only

27) Are you taking oral contraceptives?*
No
Yes

Yes, specify:
28) Any recent changes to or from your contraceptive treatment?*
No
Yes

If so, what and when?
29) Are you pregnant or trying to become pregnant?*
No
Yes
30) Are you lactating?*
No
Yes
31) Any menopause problems?*
No
Yes

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. 

Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information
Single:*
No
Yes
Married:*
No
Yes

If yes, anniversary date:

Employer:

Occupation:
Does your job require that you work outdoors?*
No
Yes

We love referrals! How/who were you referred by:

What would you like to achieve from your treatment today?
1) Have you ever had a facial treatment before?*
No
Yes

Yes, when?
2) Have you ever had a body spa treatment before?*
No
Yes

Yes, when?
Massage:*
No
Yes
Salt glow:*
No
Yes
Seaweed wrap:*
No
Yes
Moor mud:*
No
Yes
Body scrub:*
No
Yes

Other:
3) Which of the following best describes your skin type?*
4) Do you have any special skin problems or concerns pertaining to your face or body?*
No
Yes

Specify:
5) Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes
In the last month?*
No
Yes
6) Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes

Describe:
7) Have you used any of these products in the last 3 months?*
No
Yes
8) Have you used an acne medication?*
No
Yes

Yes, when?

Which drug?

Soap

Toner

Mask

Eye Product

Cleanser

Day Moisturizer

Exfoliator

Scrubs

Shower Gels

Body Lotions

Sunscreen

SPF

Night Moisturizer/Cream

Other

Makeup Products

9) What skin care products are you currently using? (List brand where known)
10) Have you recently used any self-tanning lotions, creams or treatments?*
No
Yes

Yes, specify:
11) Have you used any of the following hair removal methods in the past six weeks?*
No
Yes
Yes, check all that apply.
Shaving
Waxing
Electrolysis
Tweezing
Stringing
Depilatories
12) What areas of concern do you have regarding your Skin:
Breakouts/acne
Blackheads/whiteheads
Excessive oil/shine
Rosacea
Broken capillaries
Redness/ruddiness
Sun spot/liver spot/brown spot
Uneven skin tone
Sun damage
Wrinkles/fine lines
Dull/dry skin
Flaky skin
Dehydrated
Other

If Other:
What areas of concern do you have regarding your Eyes:
dehydrated
wrinkles
puffiness
dark circles
Other

If Other:
What areas of concern do you have regarding your Lips:
dehydrated
cracked/chapped lips
Other

If Other:
13) Have you ever had an allergic reaction to any of the following? (Please check any that apply)
Cosmetics
Medicine
Food
Animals
Sunscreens
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex
Drugs
Other

Please explain:

14) What SPF do you use on your face?

How often/when?

15) What SPF do you use on your body?

How often/when?
16) Have you had any recent tanning bed or sun exposure that changed the color of your skin?*
No
Yes

Specify:
17) Have you received Botox, Restylane or Collagen injections?*
No
Yes

If so, what and when:

Female Clients Only: 

18) Are you taking oral contraceptives?*
No
Yes

If so, what and when:
20) Are you pregnant or trying to become pregnant?*
No
Yes
21) Are you lactating?*
No
Yes
22) Any menopause problems?*
No
Yes

Specify:
23) Are you undergoing any hormone replacement therapy?*
No
Yes

Specify:

Male Clients Only: 

24) What is your current shaving system?
Wet Shave
Electric
25) Do you experience irritation from shaving?*
No
Yes
Ingrown hairs?*
No
Yes

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

Future Appointments/Contact: 

May I call/text you at your home, work or cell phone number you provided to confirm future appointments?*
No
Yes
May I contact you via text/mail/email about future monthly specials, new treatments, and news?*
No
Yes

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previ- ous 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. The treatments I receive here are voluntary and I release this institution and/or skin care profes- sional from liability and assume full responsibility thereof. 

HEALTH HISTORY


Physician:

Phone:
1) Have you been under the care of a physician, dermatologist or other medical professional within the past year?*
No
Yes

Yes, explain:
2) Any recent surgery, including plastic surgery?*
No
Yes

Yes, explain:
3) Any skin cancer?*
No
Yes

Yes, explain:
4) Have you had any piercings, tattoos, or permanent cosmetics?*
No
Yes

If yes, where on your person?
5) Have you ever had a body spa treatment before?*
No
Yes

Yes, when?
6) Have you had any of these health conditions in the past or present?
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)
Hepatitis
Herpes
Frequent cold sores
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
7) Has your physician discussed concerns about raising your body temperature?*
No
Yes

Yes, explain:
8) Do you smoke?*
No
Yes
9) Do you follow a restricted diet?*
No
Yes

Yes, specify:
10) Do you follow a regular exercise program?*
No
Yes
11) What is your stress level?*

List any medications you take regularly:

List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:
12) Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?*
No
Yes

Yes, explain:
13) Have you used any of these products in the last 3 months?*
No
Yes
14) Have you used an acne medication?*
No
Yes

Yes, when?

Which drug?
15) Do you form thick or raised scars from cuts or burns?*
No
Yes
16) Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
No
Yes

Yes, describe:

List your daily consumption of Water:

List your daily consumption of Caffeine:

List your daily consumption of Alcohol:
17) Do you experience any problems sleeping?*
No
Yes

18) How many hours do you typically sleep each night?
19) Do you wear contact lenses?*
No
Yes
20) Have you been exposed to the sun or used a tanning bed in the last 48 hours?*
No
Yes
21) How frequently are you exposed to the sun or use a tanning bed?*
22) Do you have any metal implants or wear a pacemaker?*
No
Yes
23) Have you ever experienced claustrophobia?*
No
Yes
24) Do you suffer from sinus problems?*
No
Yes
25) Have you ever had an adverse reaction after using any skin care product? (Please check any that apply)
Rash
Irritation
Peeling
Sun Senstitivity
Breakout
26) Have you ever had an allergic reaction to any of the following? (Please circle any that apply)
Cosmetics
Medicine
Food
Animals
Sunscreens
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex Drugs
Other

If Other:

If yes, please explain:

Female Clients Only

27) Are you taking oral contraceptives?*
No
Yes

Yes, specify:
28) Any recent changes to or from your contraceptive treatment?*
No
Yes

If so, what and when?
29) Are you pregnant or trying to become pregnant?*
No
Yes
30) Are you lactating?*
No
Yes
31) Any menopause problems?*
No
Yes

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. 

Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information
Single:*
No
Yes
Married:*
No
Yes

If yes, anniversary date:

Employer:

Occupation:
Does your job require that you work outdoors?*
No
Yes

We love referrals! How/who were you referred by:

What would you like to achieve from your treatment today?
1) Have you ever had a facial treatment before?*
No
Yes

Yes, when?
2) Have you ever had a body spa treatment before?*
No
Yes

Yes, when?
Massage:*
No
Yes
Salt glow:*
No
Yes
Seaweed wrap:*
No
Yes
Moor mud:*
No
Yes
Body scrub:*
No
Yes

Other:
3) Which of the following best describes your skin type?*
4) Do you have any special skin problems or concerns pertaining to your face or body?*
No
Yes

Specify:
5) Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes
In the last month?*
No
Yes
6) Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?*
No
Yes

Describe:
7) Have you used any of these products in the last 3 months?*
No
Yes
8) Have you used an acne medication?*
No
Yes

Yes, when?

Which drug?

Soap

Toner

Mask

Eye Product

Cleanser

Day Moisturizer

Exfoliator

Scrubs

Shower Gels

Body Lotions

Sunscreen

SPF

Night Moisturizer/Cream

Other

Makeup Products

9) What skin care products are you currently using? (List brand where known)
10) Have you recently used any self-tanning lotions, creams or treatments?*
No
Yes

Yes, specify:
11) Have you used any of the following hair removal methods in the past six weeks?*
No
Yes
Yes, check all that apply.
Shaving
Waxing
Electrolysis
Tweezing
Stringing
Depilatories
12) What areas of concern do you have regarding your Skin:
Breakouts/acne
Blackheads/whiteheads
Excessive oil/shine
Rosacea
Broken capillaries
Redness/ruddiness