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Patient Health History Form

Today's Date: May 16, 2021

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Your Health

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

If 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)
Any active infection
Arthritis
Asthma
Blood clotting abnormalities
Cancer
Diabetes
Eczema
Epilepsy
Fever blisters
Frequent cold sores
Headaches (chronic)
Heart problem
Hepatitis
Herpes
High blood pressure
HIV/AIDS
Hormone imbalance
Hysterectomy
Immune disorders
Insomnia
Keloid scarring
Lupus
Metal bone pins or plates
Phlebitis, blood clots, poor circulation
Psychological treatment
Seizure disorder
Skin disease/skin lesions
Spinal injury
Systemic disease
Thyroid condition
Varicose veins
7) Has your physician discussed concerns about raising your body temperature?*
No
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, describe:
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 Sensitivity
Breakout
26) Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain)
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?

Yes, specify:
28) Any recent changes to or from your contraceptive treatment?

If so, what and when?
29) Are you pregnant or trying to become pregnant?
30) Are you lactating?
31) Any menopause problems?*

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 Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Your Health

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

If 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)
Any active infection
Arthritis
Asthma
Blood clotting abnormalities
Cancer
Diabetes
Eczema
Epilepsy
Fever blisters
Frequent cold sores
Headaches (chronic)
Heart problem
Hepatitis
Herpes
High blood pressure
HIV/AIDS
Hormone imbalance
Hysterectomy
Immune disorders
Insomnia
Keloid scarring
Lupus
Metal bone pins or plates
Phlebitis, blood clots, poor circulation
Psychological treatment
Seizure disorder
Skin disease/skin lesions
Spinal injury
Systemic disease
Thyroid condition
Varicose veins
7) Has your physician discussed concerns about raising your body temperature?*
No
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, describe:
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 Sensitivity
Breakout
26) Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain)
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?

Yes, specify:
28) Any recent changes to or from your contraceptive treatment?

If so, what and when?
29) Are you pregnant or trying to become pregnant?
30) Are you lactating?
31) Any menopause problems?*

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 Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Your Health

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

If 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)
Any active infection
Arthritis
Asthma
Blood clotting abnormalities
Cancer
Diabetes
Eczema
Epilepsy
Fever blisters
Frequent cold sores
Headaches (chronic)
Heart problem
Hepatitis
Herpes
High blood pressure
HIV/AIDS
Hormone imbalance
Hysterectomy
Immune disorders
Insomnia
Keloid scarring
Lupus
Metal bone pins or plates
Phlebitis, blood clots, poor circulation
Psychological treatment
Seizure disorder
Skin disease/skin lesions
Spinal injury
Systemic disease
Thyroid condition
Varicose veins
7) Has your physician discussed concerns about raising your body temperature?*
No
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, describe:
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 Sensitivity
Breakout
26) Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain)
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?

Yes, specify:
28) Any recent changes to or from your contraceptive treatment?

If so, what and when?
29) Are you pregnant or trying to become pregnant?
30) Are you lactating?
31) Any menopause problems?*

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 Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Your Health

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

If 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)
Any active infection
Arthritis
Asthma
Blood clotting abnormalities
Cancer
Diabetes
Eczema
Epilepsy
Fever blisters
Frequent cold sores
Headaches (chronic)
Heart problem
Hepatitis
Herpes
High blood pressure
HIV/AIDS
Hormone imbalance
Hysterectomy
Immune disorders
Insomnia
Keloid scarring
Lupus
Metal bone pins or plates
Phlebitis, blood clots, poor circulation
Psychological treatment
Seizure disorder
Skin disease/skin lesions
Spinal injury
Systemic disease
Thyroid condition
Varicose veins
7) Has your physician discussed concerns about raising your body temperature?*
No
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, describe:
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 Sensitivity
Breakout
26) Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain)
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?

Yes, specify:
28) Any recent changes to or from your contraceptive treatment?

If so, what and when?
29) Are you pregnant or trying to become pregnant?
30) Are you lactating?
31) Any menopause problems?*

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 Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Your Health

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

If 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)
Any active infection
Arthritis
Asthma
Blood clotting abnormalities
Cancer
Diabetes
Eczema
Epilepsy
Fever blisters
Frequent cold sores
Headaches (chronic)
Heart problem
Hepatitis
Herpes
High blood pressure
HIV/AIDS
Hormone imbalance
Hysterectomy
Immune disorders
Insomnia
Keloid scarring
Lupus
Metal bone pins or plates
Phlebitis, blood clots, poor circulation
Psychological treatment
Seizure disorder
Skin disease/skin lesions
Spinal injury
Systemic disease
Thyroid condition
Varicose veins
7) Has your physician discussed concerns about raising your body temperature?*
No
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, describe:
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 Sensitivity
Breakout
26) Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain)
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?

Yes, specify:
28) Any recent changes to or from your contraceptive treatment?

If so, what and when?
29) Are you pregnant or trying to become pregnant?
30) Are you lactating?
31) Any menopause problems?*

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 Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Your Health

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

If 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)
Any active infection
Arthritis
Asthma
Blood clotting abnormalities
Cancer
Diabetes
Eczema
Epilepsy
Fever blisters
Frequent cold sores
Headaches (chronic)
Heart problem
Hepatitis
Herpes
High blood pressure
HIV/AIDS
Hormone imbalance
Hysterectomy
Immune disorders
Insomnia
Keloid scarring
Lupus
Metal bone pins or plates
Phlebitis, blood clots, poor circulation
Psychological treatment
Seizure disorder
Skin disease/skin lesions
Spinal injury
Systemic disease
Thyroid condition
Varicose veins
7) Has your physician discussed concerns about raising your body temperature?*
No
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, describe:
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 Sensitivity
Breakout
26) Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain)
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?

Yes, specify:
28) Any recent changes to or from your contraceptive treatment?

If so, what and when?
29) Are you pregnant or trying to become pregnant?
30) Are you lactating?
31) Any menopause problems?*

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 Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Your Health

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

If 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)
Any active infection
Arthritis
Asthma
Blood clotting abnormalities
Cancer
Diabetes
Eczema
Epilepsy
Fever blisters
Frequent cold sores
Headaches (chronic)
Heart problem
Hepatitis
Herpes
High blood pressure
HIV/AIDS
Hormone imbalance
Hysterectomy
Immune disorders
Insomnia
Keloid scarring
Lupus
Metal bone pins or plates
Phlebitis, blood clots, poor circulation
Psychological treatment
Seizure disorder
Skin disease/skin lesions
Spinal injury
Systemic disease
Thyroid condition
Varicose veins
7) Has your physician discussed concerns about raising your body temperature?*
No
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, describe:
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 Sensitivity
Breakout
26) Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain)
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?

Yes, specify:
28) Any recent changes to or from your contraceptive treatment?

If so, what and when?
29) Are you pregnant or trying to become pregnant?
30) Are you lactating?
31) Any menopause problems?*

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. 

Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Your Health

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

If 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)
Any active infection
Arthritis
Asthma
Blood clotting abnormalities
Cancer
Diabetes
Eczema
Epilepsy
Fever blisters
Frequent cold sores
Headaches (chronic)
Heart problem
Hepatitis
Herpes
High blood pressure
HIV/AIDS
Hormone imbalance
Hysterectomy
Immune disorders
Insomnia
Keloid scarring
Lupus
Metal bone pins or plates
Phlebitis, blood clots, poor circulation
Psychological treatment
Seizure disorder
Skin disease/skin lesions
Spinal injury
Systemic disease
Thyroid condition
Varicose veins
7) Has your physician discussed concerns about raising your body temperature?*
No
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, describe:
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 Sensitivity
Breakout
26) Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain)
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?

Yes, specify:
28) Any recent changes to or from your contraceptive treatment?

If so, what and when?
29) Are you pregnant or trying to become pregnant?
30) Are you lactating?
31) Any menopause problems?*

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. 

Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Your Health

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

If 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)
Any active infection
Arthritis
Asthma
Blood clotting abnormalities
Cancer
Diabetes
Eczema
Epilepsy
Fever blisters
Frequent cold sores
Headaches (chronic)
Heart problem
Hepatitis
Herpes
High blood pressure
HIV/AIDS
Hormone imbalance
Hysterectomy
Immune disorders
Insomnia
Keloid scarring
Lupus
Metal bone pins or plates
Phlebitis, blood clots, poor circulation
Psychological treatment
Seizure disorder
Skin disease/skin lesions
Spinal injury
Systemic disease
Thyroid condition
Varicose veins
7) Has your physician discussed concerns about raising your body temperature?*
No
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, describe:
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 Sensitivity
Breakout
26) Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain)
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?

Yes, specify:
28) Any recent changes to or from your contraceptive treatment?

If so, what and when?
29) Are you pregnant or trying to become pregnant?
30) Are you lactating?
31) Any menopause problems?*

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. 

Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Your Health

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

If 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)
Any active infection
Arthritis
Asthma
Blood clotting abnormalities
Cancer
Diabetes
Eczema
Epilepsy
Fever blisters
Frequent cold sores
Headaches (chronic)
Heart problem
Hepatitis
Herpes
High blood pressure
HIV/AIDS
Hormone imbalance
Hysterectomy
Immune disorders
Insomnia
Keloid scarring
Lupus
Metal bone pins or plates
Phlebitis, blood clots, poor circulation
Psychological treatment
Seizure disorder
Skin disease/skin lesions
Spinal injury
Systemic disease
Thyroid condition
Varicose veins
7) Has your physician discussed concerns about raising your body temperature?*
No
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, describe:
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 Sensitivity
Breakout
26) Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain)
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?

Yes, specify:
28) Any recent changes to or from your contraceptive treatment?

If so, what and when?
29) Are you pregnant or trying to become pregnant?
30) Are you lactating?
31) Any menopause problems?*

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. 

Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Your Health

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

If 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)
Any active infection
Arthritis
Asthma
Blood clotting abnormalities
Cancer
Diabetes
Eczema
Epilepsy
Fever blisters
Frequent cold sores
Headaches (chronic)
Heart problem
Hepatitis
Herpes
High blood pressure
HIV/AIDS
Hormone imbalance
Hysterectomy
Immune disorders
Insomnia
Keloid scarring
Lupus
Metal bone pins or plates
Phlebitis, blood clots, poor circulation
Psychological treatment
Seizure disorder
Skin disease/skin lesions
Spinal injury
Systemic disease
Thyroid condition
Varicose veins
7) Has your physician discussed concerns about raising your body temperature?*
No
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, describe:
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 Sensitivity
Breakout
26) Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain)
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?

Yes, specify:
28) Any recent changes to or from your contraceptive treatment?

If so, what and when?
29) Are you pregnant or trying to become pregnant?
30) Are you lactating?
31) Any menopause problems?*

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. 

Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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