Client Health History Form Georgian College (Page 2 of 2) in pdf

Additional comments &/or concerns: ___________________________________________________

________________________________________________________________________________

Please list all medications you are currently taking and the condition it treats: ___________________

________________________________________________________________________________

Please list all allergies: _____________________________________________________________

Have you ever had an allergic reaction to a product applied to your skin? Yes _____ No _____

If yes, which products or ingredients? __________________________________________________

Describe your skin and your present skin care regime? ____________________________________

________________________________________________________________________________

What skin care product line are you currently using?

_______________________________________ Do you like it? Yes _____ No_____

Do you have a specific skin condition do you wish to correct? _______________________________

Do you tan in a tanning bed? Yes _____ No _____

Do you use tobacco products? Yes _____ No _____

If Yes, what products and how frequently? ___________

Do you use Accutane, Retinol, Tretinoin or Prescription Vitamin A on your skin? Yes _____ No_____

Please list sensitivities: __________________________________________________________

Are you currently under the care of a dermatologist? Yes _____ No_____

Do you have any internal pins, wires, artificial joints or metal implants? Yes _____ No _____

If so, where are they located? ________________________________________________________

Are you on any type of hormone therapy? Yes _____ No_____

Do you wear contact lenses? Yes _____ No_____

Women only: Are you pregnant or trying to become pregnant? Yes _____ No_____

If yes to being pregnant, when is your due date? ________________________

I certify that the information above is true and correct. I understand that it is my responsibility to

inform the Esthetic Student and Staff of my current medical or health concerns, which are essential

for proper treatment. My signature below constitutes my consent to treatment. I hereby give my

consent and authorization voluntarily and release this establishment and its agents of any claims that

I have or may have in the future connection with the treatment.

Client Name: _____________________________ Signature: ____________________________

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Student Name: ______________________ Date: ____________

(PRINT)

Admin Use only: Medical History Updates

Date

Changes or No Significant Findings (NSF)

Student

Staff

(DD/MM/YY)

Client Health History Form Georgian College Page 2