Facial Intake Form
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2WELCOME TO HIRED HANDS DAY SPA & SALON (Facial Form)
Name: ____________________________________________________________Home Phone:_________________________
Address:__________________________________________________________ Work Phone:__________________________
City:_________________________________ ________ State:________ Zip:__________ Cell:_________________________
Occupation:________________________ Employer:______________ E-Mail Address: _______________________________
How did you find out about Hired Hands?:_____________________________________ D.O.B. _______________________
In case of emergency, please notify:_________________________________________ @ phone #______________________
May we add you to our mailing list? ____yes ____ no Have you received a professional facial before? ____yes
_____ no
Your Health
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1. Within the last year, have you been under a physician’s care?
yes
no
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2. Within the last year, have you been under a dermatologist’s care?
yes
no
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3. Within the last nine months, have you undergone any surgery?
yes
no
If yes, please specify______________________________________________________________
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4. Do you have any known allergies?
yes
no
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Aspirin or Salicylates
Milk
Apples
Citrus
Grapes
Ingredients in Skin Care Products
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Latex __Sulfur
Fish, Marine or Iodine
5.
Have you had any of these health problems in the past or present?
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Cancer
Diabetes
Epilepsy
Heart problems
Hormone imbalance
Spinal injury
Hysterectomy
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Thyroid condition
Varicose veins
Systemic disease
Cold sores
Claustrophobia
Hepatitis
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High/low blood pressure
Autoimmune disorder
Stroke
Fainting
Asthma
Eating disorder
6. List any medications, supplements, vitamins, diuretics, slimming tablets, etc. that you take regularly
_____________________________________________________________________________________________
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7. Do you have regular sleep patterns?
yes
no
10.
Do you wear contact lens?
yes
no
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8. Do you regularly exercise?
yes
no
11.
Do you follow a restricted diet?
yes
no
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9. Do you have metal implants or a pacemaker?
yes
no
12.
Do you smoke?
yes
no
Skin Care History
13. Have you ever had a chemical peel, laser, microdermabrasion or any resurfacing treatments?
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yes
no
in the last month?
yes
no
14. Do you use Accutane, Retin A, Renova, Adapalene, Triluma, Metrogel, or Tazarotene?
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yes
no
in the last 3 month?
yes
no
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15. Do you use an acne medication?
yes
no
in the last 6 month?
yes
no
16. Are you currently using any products that contain the following ingredients?
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Glycolic Acid
Benzoyl Peroxide
Resorcinol
Salicylic Acid
Lactic Acid
Any exfoliating scrubs
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Any hydroxy acid products (AHA or BHA)
Vitamin A derivatives
17. Do you have or have you had any of the following in the last 14 days?
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Facial Cosmetic Surgery
Botox Injections
Collagen Injections
Fillers
Light Treatments
18. What Skin Care products are you currently using?
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Parent category: Medical