Facial Intake Form

Physician

Emergency Contact

Name

Relation

Phone #

Your Health

Have you been under the care of a physician, dermatologist, or other medical professional within the past year?
YesNo

Any recent surgery, including plastic surgery?
YesNo

Any skin cancer?
YesNo

Have you had any piercings, tattoos, or permanent cosmetics?
YesNo

Have you ever had a body spa treatment before?
YesNo

Have you had any of these health conditions in the past or present?
CancerHormone ImbalanceSystemic DiseaseHigh Blood PressureSpinal InjuryThyroid ConditionHysterectomyDiabetesHeart ProblemVaricose VeinsArthritisAsthmaEczemaEpilepsySeizure DisorderFever BlistersHeadaches (chronic)HepatitisHerpesFrequent Cold SoresImmune DisordersHIV/AIDSLupusMetal Bone Pins or PlatesPhlebitis, Blood Clots, Poor CirculationBlood Clotting AbnormalitiesPsychological TreatmentInsomniaKeloid ScarringSkin Disease / Skin LesionsAny Active Infections

Has your physician discussed concerns about raising your body temperature?
YesNo

Do you smoke?
YesNo


Do you follow a restricted diet?
YesNo

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

Have you used any of these products in the last 3 months?
YesNo


Have you used an acne medication?
YesNo

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

List your daily consumption of:
Water:
Caffeine:
Alcohol:

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? (Please choose all that apply)
RashIrritationPeelingSun SensitivityBreakout

Have you ever had an allergic reaction to any of the following? (Please choose all that apply)
CosmeticsMedicineFoodAnimalsSunscreensIodinePollenAHAsFragranceShellfishLatexDrugs Other:
If yes, please explain:

Female Clients Only:

Are you taking oral contraceptives?
YesNo

Any recent changes to or from your contraceptive treatment?
YesNo

Are you pregnant or trying to become pregnant?
YesNo


Are you lactating?
YesNo


Any menopause problems?
YesNo

Please use this space to complete any answers where space was insufficient (Please include the number of the question)

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 discolosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatment 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.

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