Confidential Client Health History Form
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3Confidential Client Health History Form
Date: _______________________________
Name: __________________________________________________________________ Date Of Birth: __________
Address: ________________________________________________________________________________________
Home Phone: __________________________________ Business Phone: __________________________________
Cell Phone: _____________________________________________ E-mail: __________________________________
Physician: ______________________________________________Phone: __________________________________
Emergency Contact: _____________________________________Phone: __________________________________
Your Health
1) Have you been under the care of a physician, dermatologist or other medical professional within the past year?
m No m Yes, explain: ____________________________________________________________________________
2) Any recent surgery, including plastic surgery? m No m Yes, explain: ___________________________________
________________________________________________________________________________________________
3) Any skin cancer? m No m Yes, explain: ____________________________________________________________
4) Have you had any piercings, tattoos, or permanent cosmetics? m No m Yes, If yes, where on your person?
______________________________________________________________________________________________
_____________________________________________________________
5) Have you ever had a body spa treatment before? m No m Yes, when: _________________________________
6) Have you had any of these health conditions in the past or present?
(Please check all that apply and provide additional information in the space provided)
Cancer
Headaches (chronic)
o
o
Hormone imbalance
Hepatitis
o
o
Systemic disease
Herpes
o
o
High blood pressure
Frequent cold sores
o
o
Spinal injury
Immune disorders
o
o
Thyroid condition
HIV/AIDS
o
o
Hysterectomy
Lupus
o
o
Diabetes
Metal bone pins or plates
o
o
Heart problem
Phlebitis, blood clots, poor circulation
o
o
Varicose veins
Blood clotting abnormalities
o
o
Arthritis
Psychological treatment
o
o
Asthma
Insomnia
o
o
Eczema
Keloid scarring
o
o
Epilepsy
Skin disease/skin lesions
o
o
Seizure disorder
Any active infection
o
o
Fever blisters
o
7) Has your physician discussed concerns about raising your body temperature? m No m Yes
explain: ______________________________________________________________________________________
________________________________________________________________________________________________
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Parent category: Medical