Center for advanced skin care Client Profile Information
Last Name:______________________________ First Name:___________________Birthday_____________
Address:____________________________________________ City_______________ Zip_______________
Phone:_____________________Home ____________________Work ___________________Cell
Email address__________________________Occupation________________ Place of Business____________
Hobbies and Leisure Time Spent:______________________________________________________________
Emergency Contact_______________________________________ Phone____________________________
How did you hear about us:_____________________________________
MEDICAL HISTORY
Allergies___________________________________________________________________________
Major Illnesses______________________________________________________________________
Cosmetic Surgery___________________________________________________Date_____________
Current Medications__________________________________________________________________
Please circle any of the following you may have and list medications where applicable:
High/Low Blood Pressure/Medication____________
Heart Condition/Medication_____________
Varicose Veins or Varicose Bruising on feet & Ankles
Hemophiliac, Bleeding Disorder, Clotting
Impaired lymphatic System
Arthritis
Epilepsy
Asthma/Medication_____________ Claustrophobia
Heart Disease
Scoliosis
Diabetes
Cancer type__________________
HIV/AIDS
Immune Disorders type______________________
Pregnant
Breast feeding
Numbness where___________________________
Fibromyalgia
Rosacea
Osteoporosis
Migraines
Keloid Scarring
Metal Rods/Plates
Pacemaker
Other Medical devices_____________________________________
Hepatitis
Sinus Problems
Edema
Anxiety/Depression/Medications____________________________
MS/Medication________________ Epi Pen for severe allergies
Acne Medication______________
Anti-depressant Medication_______________________________________________________________
Antibiotics and Antifungal Medications______________________________________________________
Thyroid Disorder/Medication_____________________
Vitiligo
Lupus
Eczema/Medication_____________ Dermatitis/Medication__________ Psoriasis/Medication___________
Other conditions_________________________________________________________________________
Skin conditions__________________________________________________________________________
Please circle all interested in:
Skin Care Program Body Wrap
Chiropractic
Soft Tissue
Wellness Program
Nutrition
Food Intolerance
Hair Analysis
Stress Management Personal Training
Group Fitness Class Lymph Drain
Diet Planning
Hormone Balance
Alternative Health Care
Cellulite Wrap
Injectables
Candida Program
Massage
FEMALE ONLY
Hysterectomy Full/Partial Year_______
Date of Last Menstrual Cycle ___________________________
Birth Control Type____________________ Irregular Menstruation
PCOS/Medication____________
Endometriosis
Superfluous hair problems PMS Symptoms______________
Poor Sleep pattern/Medication___________ Other_______________________________________________
Circle any that apply - fill in blanks with amount per week:
Pain/Medication___________________
Stress Level: High Medium Low
Smoker/Pks a day____________
Exercise:types and times a week________________
Sensitivity____________________
Alcohol Consumption/types and amount_____________
Drugs (rec) ___________________
Eating Disorder
Anemia
NUTRITIONAL INFORMATION
What time is the main meal eaten:______________ How many meals/day & size______________________
Number of fast food meals/week__________
What type food groups___________________________
Fat free diet
Food Allergies
Food Intolerances
Quality & Quantity of fluid intake__________________________
Diabetes: type 1 or 2
Weight Flux: yes
no
List vitamins/supplements with amounts_______________________________________________________
________________________________________________________________________________________
Herbal Remedies__________________________________________________________________________
Caffeine intake_____ Chiropractor
Acupuncture
SKIN HISTOLOGY
A. DETERMINATION BASED ON YOUR HEREDITARY DISPOSITION
1. What is your eye color?
Light blue, grey, green
Blue, grey, or green
2. What is your hair color?
Sandy red
Blond
Reddish
Many
3. What is the color of your
untanned skin?
4. Are there freckles on your
untanned skin?
Blue
Chestnut/dark “dirty”
blond
Dark brown
Very pale
Pale with beige tint
Light brown
Several
Few
Incidental
Dark brown
B. DETERMINATION BASED ON YOUR SUNBATHING HABITS
1. What happens when you
stay long in the sun?
2. To what degree do you tan
in the sun?
3. Do you turn grey-brown
directly after sunbathing?
4. How does your face react to
the sun?
Painful redness,
blistering, peeling
Burns regularly with
peeling
Burns sometimes with
peeling
Burns rarely
Hardly or not at all
Tan a little
Tan reasonably
Tans very easily
Never
Hardly
Sometimes
Often
Very sensitive
Sensitive
Normal
Very resistant
C. YOUR TANNING HABITS
1.When sunbathing, do you
try to tan your whole body?
2. When did you last sunbathe
(indoors or outdoors)?
Never
Rarely
Sometimes
Often
More than 3 months
ago
2-3 months ago
1-2 moths ago
Less than 1 month ago
Tanning Bed History______________________
Sunburn History_____________________________
Where did you grow up for the first 25 years___________________________________________________
Heritage/Ethnicity (not race)___________________________________________________________________
Red Head gene: MC1R
Have you had or used any of the following? Please put dose, frequency and date last used:
Botox___________ Fillers_________
Cosmetic Surgery________ Dermatologist Care__________
Accutane_________ Retin A________
Chemical Peels__________ Laser Treatments____________
Dermabrasion______ Enzyme Peels____
Exfoliations____________
Mole Removal______________
Pre cancerous______ Lesion Removal___ Hair Removal___________ Cold Sores_________________
Hydroquinone______ Bleaching Cremes___ Tanning Beds___________ Sunless Tanning Crème_______
Topical Acne Medications_______________Recent Dental Work______ Contact Lenses
Home Skin Care Products
Cleanser/brand and times a day____________________ Toner/brand and times a day___________________
Moisture: Night crème/brand _____________________ Day Crème/brand___________________________
Eye Crème/brand and times a day__________________ Serum(s)/brand and times a day___________________
Exfoliator/brand and times a week__________________ Sunscreen/brand___________________
Mask/brand and times a week___________________
Circle Areas of Concern:
Cellulite
Wrinkles
Tight Neck
Tight Shoulders
Skin Elasticity
Sun Damage
Acne Scarring
Uneven Skin Tone
Makeup_____________________________________
Crows Feet
Sore Muscles
Dry Skin
Acne
Psoriasis
Eczema
Other________________________________________
What 3 things would you change about your skin________________________________________________
Where do you hold your stress_____________________________________________________________
What do you want/expect from this treatment_____________________________________________________
Please Initial
______I agree to avoid direct sun after treatment
______I agree to notify therapist with any concerns
______I do not have active cold sores
______I do not need a doctor’s release
I understand that aesthetic services offered are not a substitute for medical care and any information provided
by the therapist(s) is for educational purposes only and not diagnostically prescriptive in nature. I understand
that the information herein is to aid the therapist in providing a better service and is completely confidential.
Failure to alert the therapist of any conditions could result in unfavorable outcomes with the treatment.
As with all skin care treatments, there is no guarantee of results. Those with cold sores could have a breakout
after treatments. Depending on the treatment(s), I may experience some temporary stinging, warm flushing or
even mild discomfort. Some of these effects can last for upwards of 10-14 days depending on. Body work may
cause some soreness, bruising and tingling after treatment. Adequate water consumption is critical as well as
following home care protocols.
We do require a 24 hour cancellation. If less than a 24 hour notice, we will charge a flat fee of $50. No
show/no call appointments will be charged 50% of the appointment cost.
I fully understand and agree to the above policies and have filled the history sheet correctly and accurately. I
hereby give my consent and authorization voluntarily and release Center for Advanced Skin Care as well as the
therapist(s) from any claims, implied or stated that I have or may have in the future with this of any treatment,
regardless of the results. I am stating that the treatments and precautions above have been explained to me in
detail and that I fully understand.
__________________________________________________
Client Signature
__________________________
Date