Facial/body Health History Form
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1
2Facial/Body Health History
Form
General
Client Name:______________________________Date:_____________Address:
_________________________________________________
City:_________________________State:
_____
Zip: _________Phone Number:
_________________________
Cell Home Work (circle)
Email: ___________________________Birthday: _________________Age:
Under 21
21-30
31-40
41-50
51-60
61+
c
c
c
c
c
c
Emergency Contact:
______________________________________________________
Phone:
_____________________________________
What are your primary skin care
goals/concerns?__________________________________________________________________________
What other treatments are you interested in? (circle all that apply):
Facial Treatment
Waxing
Spa Treatment
Body Treatment
Skin
Have you had chemical peels, microdermabrasion, or any resurfacing treatments? If yes, specify:
_______________________________
Do you use any prescription skin products (i.e. Accutane, Retin-A, Renova, Adapalene) If yes, specify:
___________________________
Please circle all that apply:
Are you currently using any products that contain any of the following ingredients?
Glycolic Acid
Lactic Acid
Salicylic Acid
Exfoliating Scrubs
Vitamin A Derivatives
Do you have a tendency to redness?
Do you experience an oily shine throughout the day?
Do you ever experience skin breakouts?
What are you using in your current skin care regime (check all that apply and specify brand and type): Soap
c _____________________
Cleanser
_______________________Toner
_____________________________Exfoliator
c __________________________________
c
c
Moisturizer
_______________________Sun Protection
___________________________Mask
c
c
c______________________________
Specialty
________________________________Eye Treatment
__________________Other Products:
_________________________
c
c
Male Clients only:
What products do you use during your shaving
regime?___________________________________________________________________
Do you experience shaving irritation/ingrown hairs?
yes
no
c
c
How many times do you shave per week?
0-2
3-5
6-7
7+
c
c
c
c
Health
Have you been under a physician’s care within the last year?
yes
no If yes,
specify:_____________________________________
c
c
List any regularly taken medications, vitamins, supplements,
etc..___________________________________________________________
Please circle all that apply:
Blood Pressure Heart Problems Pacemaker Diabetes Epilepsy Asthma Sinus Problems Hormonal Problems
Cold Sores
Claustrophobia Recent Dental X-rays Metal Implants or Body Piercings Vericose Veins: If yes, specify location:
_______________
Have you had allergic reactions to any of the following: Fragrances: If yes,
specify:____________________________________________
Food: If yes,
specify:_________________________________
Animals: If yes, specify:
____________________________________________
Medicine: If yes,
specify:______________________________
Cosmetics: If yes,
specify:__________________________________________
Specific Ingredients: If yes, specify: ___________________________Other:
____________________________________________________
Other health issues:
yes
no If yes, specify:
_________________________________________________________________________
c
c
_____________________________________________________________________________________________________________________
Female Clients only:
Are you taking oral contraception?
yes
no
Currently having or due for your menstrual period?
yes
no
c
c
c
c
Are you pregnant or trying to become pregnant?
yes
no Are you currently breast feeding?
yes
no
c
c
c
c
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Parent category: Medical