Confidential Client Health History Form (Page 2 of 3) in pdf

Confidential Client Health History Form—continued

8) Do you smoke? m No m Yes

9) Do you follow a restricted diet? m No m Yes, specify: ________________________________________________

10) Do you follow a regular exercise program? m No m Yes

11) What is your stress level? High o

Medium o

Low o

List any medications you take regularly: _____________________________________________________________

List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:

________________________________________________________________________________________________

12) Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or

Retinol/vitamin A derivative products? m No m Yes, describe: _______________________________________

13) Have you used any of these products in the last 3 months? m No m Yes

14) Have you used an acne medication? m No m Yes, when? ___________ Which drug?___________________

15) Do you form thick or raised scars from cuts or burns? m No m Yes

16) Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or

marks after physical trauma? m No m Yes, describe: ______________________________________________

List your daily consumption of: Water ______________ Caffeine ______________ Alcohol ______________

17) Do you experience any problems sleeping? m No m Yes

18) How many hours do you typically sleep each night? __________

19) Do you wear contact lenses? m No m Yes

20) Have you been exposed to the sun or used a tanning bed in the last 48 hours? m No m Yes

21) How frequently are you exposed to the sun or use a tanning bed? ___Infrequently ___Frequently ___Regularly

22) Do you have any metal implants or wear a pacemaker? m No m Yes

23) Have you ever experienced claustrophobia? m No m Yes

24) Do you suffer from sinus problems? m No m Yes

25) Have you ever had an adverse reaction after using any skin care product? (Please circle any that apply)

Rash

Irritation

Peeling

Sun Sensitivity

Breakout

26) Have you ever had an allergic reaction to any of the following? (Please circle any that apply and explain)

Cosmetics

Medicine

Food

Animals

Sunscreens

Iodine

Pollen

AHAs

Fragrance

Shellfish

Latex

Drugs

Other: ________________

Continued a

member

Associated Skin Care Professionals

Confidential Client Health History Form Page 2

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