New Patient History Form

Patient's Name

Date Of Birth

Address

Home Phone

Business Phone

Cell Phone

Email

Physician

Physician's Phone

Emergency Contact

Emergency Contact's Phone

Have you been under the care of a physician, dermatologist or other medical professional within the past year?YesNo(if yes, please provide additional information below)

Any recent surgery, including plastic surgery? YesNo(if yes, please provide additional information below)

Any skin cancer?YesNo(if yes, please provide additional information below)

Have you had any piercings, tattoos, or permanent cosmetics?YesNo(if yes, please provide additional information below)

Have you ever had a body spa treatment before?YesNo (if yes, please provide additional information below)

Have you had any of these health conditions in the past or present? YesNo

CancerHormone imbalanceSystemic diseaseHigh blood pressureSpinal injuryThyroid conditionHysterectomyDiabetesHeart problemVaricose veinsArthritisAsthmaEczemaEpilepsySeizure disorderFever blistersHeadaches (chronic)HepatitisHerpesFrequent cold soresImmune disordersHIV/AIDSLupusMetal bone pins or platesPhlebitisBlood clotsPoor circulationBlood clotting abnormalitiesPsychological treatmentInsomniaKeloid scarringSkin disease/skin lesionsAny active infection(Please check all that apply and provide additional information in the space provided below)

Has your physician discussed concerns about raising your body temperature?YesNo
Please explain:
Do you smoke?YesNo
Do you follow a restricted diet?YesNo
Please specify

Do you follow a regular exercise program?YesNo
What is your stress level?HighMediumLow
List any medications you take regularly:
List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?YesNo
Please describe
Have you used any of these products in the last 3 months?YesNo
Have you used an acne medication?YesNo Please indicate when and which drug
Do you form thick or raised scars from cuts or burns?YesNo
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma? YesNo
Please describe
List your daily consumption of: WaterCaffeineAlcohol
Do you experience any problems sleeping?YesNo
How many hours do you typically sleep each night?
Do you wear contact lenses?YesNo
Have you been exposed to the sun or used a tanning bed in the last 48 hours?YesNo
How frequently are you exposed to the sun or use a tanning bed?InfrequentlyFrequentlyRegularly
Do you have any metal implants or wear a pacemaker?YesNo
Have you ever experienced claustrophobia?YesNo
Do you suffer from sinus problems?YesNo
Have you ever had an adverse reaction after using any skin care product?RashIrritationPeelingSun SensitivityBreakout
Have you ever had an allergic reaction to any of the following? CosmeticsMedicineFoodAnimalsSunscreensIodinePollenAHAsFragranceShellfishLatexDrugsOther
If yes, please explain:

Female Clients Only:

Are you taking oral contraceptives?YesNo
If yes, please specify
Any recent changes to or from your contraceptive treatment?YesNo
If so, what and when?
Are you pregnant or trying to become pregnant?YesNo
Are you lactating?YesNo
Any menopause problems?YesNo
If yes, please specify

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the esthetician/skin care therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.

Please sign your name below