Creative Skin Care
Client Information & Medical History
In order to provide you with the most appropriate treatment, we need you to complete the following questionnaire. All
information is strictly confidential.
PERSONAL HISTORY
Today’s Date : ___/_____/______
Client Name:_____________________________________________
Email Address (Please Print):____________________________________ Date of Birth: ___/_____/______
Home Address:_____________________________________
Home Phone: ___/_____/______
City:_________
Cell Phone: ___/_____/______
State:____
Age____
Zip Code:______
Occupation___________________________
Emergency Contact Name:___________________________ Phone#: ___/_____/______ Relation:_________________
How were you referred to us? ________________________ What treatment are you having today? _________________
Concerns/Interests
o Unwanted hair
o Wrinkles
o Pigmentation
o Body
o Acne
o Large pore size
o Brown spots
countering
o Rosacea
o Discoloration
o Broken
o Body Tanning
o Dryness
o Loss of skin
capillaries/veins
o Veins
o Fine Lines
tone
o Body detox
Other:_____________________________________________
Ethnic background: ________________________________
Which of the following best describes your skin type? (Please circle one type number)
I
Always burns, never tans
IV
Rarely burns, always tans
II
Always Burns, Sometimes tans
V
Brown, moderately pigmented skin
III
Sometimes burns, always tans
VI
Black Skin
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Y/N
Do you regularly use tanning salons or sun bathe? If yes last date of tanning _________
Are you using Biore/Snore stripes? (Discontinue 5 days before & after treatment)
Are you using Depilatories? (Discontinue for 7days before & after
treatment)
Have you had any of the following within the last 14 days: Chemical Peel, Microdermabrasion, or any
procedure with a medical device?
Do you have regular injections of collagen, Botox, Restylane or others?
Have you recently had facial surgery? Describe: _______________________________
Have you recently had laser resurfacing? If so when:____________________________
MEDICAL HISTORY
Y/N
Are currently under the care of a Physician? If yes, for what: _____________________________________
Y/N
Are you currently under the care of a Dermatologist? If yes, for what: ______________________________
Y/N
Do you have a history of erythema abigne, which is a persistent skin rash produced by prolonged or repeated
exposure to moderately intense heat or infrared irritation?
Y/N
Do you have any of the following medical conditions? (Please circle all that apply)
Cancer/ Diabetes/ High blood pressure/ Herpes/ Arthritis/ Frequent cold sores/HIV/AIDS/ Keloid scarring/ Skin
disease/Skin lesions/ Seizure disorder/ Hepatitis/Hormone imbalance/ Thyroid imbalance/ Blood clotting abnormalities/
Any active infection
Do you have any other health problems or medical conditions? Please list:_____________________________________
Have you ever had an allergic reaction to any of the following? (Please Circle all that apply and describe the reaction you
experienced) Food/ Latex/ Aspirin/ Lidocaine/ Hydrocortisone/ Hydroquinone/ Skin bleaching agents
Other: ________________________________________________________________
MEDICATIONS
What oral medications are you presently taking?
(Birth Control Pills/ Hormones/
Others):______________________________________________________________________
Y/N
Are you on any mood altering or anti-depression medication? What:________________
Please list any medications or supplements (asprin, herbals, fish oil, etc) you are taking:
o Retin-A
o Differin
o Hydroquinone
o Renova
o Accutane
o Avage
o Other topical agents____________
What Herbal supplements do you use regularly?______________________________________
HISTORY
Y/N
Have you ever had Laser Hair Removal?
Y/N
Have you used any of the following hair removal methods in the past six weeks?
Shaving/ Waxing/ Electrolysis/ Plucking/ Tweezing/ Stringing/ Depilatories
Y/N
Have you had any recent tanning or sun exposure that changed the color of your skin?
Y/N
Have you recently used any self-tanning lotions or treatments?
Y/N
Do you form thick or raised scars from cuts or burns?
Y/N
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks
from physical trauma? If yes describe: _________________________________________________________________
For our female clients:
Y/N
Y/N
Y/N
Are you pregnant or trying to become pregnant?
Are you breastfeeding?
Are you using contraception?
I understand, I have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure.
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is
my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health
conditions and update this history. I release this institution and/or skin care professional from liability and assume full
responsibility thereof.
Fine Print: We are an appointment based business and we understand that sometimes our clients need to cancel their scheduled appointments. Please carefully read
our Cancellation Policy before booking. All scheduled appointments must be secured with a valid credit card.
We strongly enforce our 24 hour Cancellation Policy. We consider a no show to anyone who cancels less than 24 hours of appointment time or anyone who is more
than 10 minutes late for appointment. If you are late we may not have time to serve you and the clients after you that come on time. If we are not able to serve you, you
will be charged 35% of the full price service scheduled. Our clinic staff is commission based and they count on you to be on time. Thank you for respecting our time
and our effort to serve you.
Signature:______________________________________________
Date: ___/_____/______