Confidential Client Health History Form

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Your Health

Have you been under the care of a physician, dermatologist or other medical professional within the past year?
Any recent surgery, including plastic surgery?
Any skin cancer?
Have you had any piercings, tattoos, or permanent cosmetics?
Have you ever had a body spa treatment before?
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)
Has your physician discussed concerns about raising your body temperature?
Do you smoke?
Do you follow a restricted diet?
Do you follow a regular exercise program?
What is your stress level?
) Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?
Have you used any of these products in the last 3 months?
Have you used an acne medication?
Do you form thick or raised scars from cuts or burns?
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?
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List your daily consumption of
Water
Caffeine
Alcohol
 
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Do you experience any problems sleeping?
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Do you wear contact lenses?
Have you been exposed to the sun or used a tanning bed in the last 48 hours?
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How frequently are you exposed to the sun or use a tanning bed?
Infrequently
Frequently
Regularly
 
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Have you ever experienced claustrophobia?
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Do you suffer from sinus problems?
Have you ever had an adverse reaction after using any skin care product? (Please check any that apply)
Have you ever had an allergic reaction to any of the following? (Please check any that apply)

Female Clients Only:

Are you taking oral contraceptives?
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Any recent changes to or from your contraceptive treatment?
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Are you pregnant or trying to become pregnant?
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Are you lactating?
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Any menopause problems?
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