Confidential Client Health History & Consultation Form Page 2
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11. Have you had microneedling, chemical peels, laser or microdermabrasion? __No __Yes
If yes what was the date of your last treatment? __________________
12. Have you ever had an allergic reaction to any of the following? (Please check any that
apply and explain)
__Cosmetics
__Medicine
__Food
__Animals
__Sunscreen
__Iodine
__Pollen
__AHA’s
__Fragrance
__Shellfish
__Latex
__Drugs
Other________
________________________________________________________________________
13. Have you ever had an adverse reaction after using any skin care product? ( Please circle
any that apply)
Rash
Irritation
Peeling
Sun Sensitivity
Breakout
14. Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA,
Salicylic Acid or Retinol/vitamin A derivative products? __No __Yes
If Yes, when was the last time you used them? _________________________________
15. Have you been exposed to the sun or used a tanning bed in the last 48 hours? __No
__Yes If yes how frequently are you exposed? __Infrequently __Frequently
16. Do you use sunscreens? __No __Yes
What SPF do you use on your
body____,face____?
17. What is your stress level? __High __Medium __Low
18. List your daily consumption of: Water________ Caffeine__________ Alcohol________
Female Clients Only:
1. Are you taking oral contraceptives or hormone replacement therapy? __No __Yes if so,
what and when? __________________________________________________________
2. Are you pregnant or trying to become pregnant? __No __Yes
Male Clients Only:
1. What is your current shaving system? Wet shave_____ Electric______
2. Do you experience irritation from shaving? __No __Yes
Ingrown hairs? __No __Yes
Future Appointments/Contact:
May I call or text you to confirm future appointments? __No __Yes
May I contact you via mail/email about future promotions and news? __No __Yes
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