CLIENT CONSULTATION & HEALTH HISTORY
Name: ______________________________________
Date: ___________________________
Street: ____________________________________________________
City/State: ______________________________ Zip: ______________
Cell Phone # ______________________ Email: _______________________________________
Cell Phone Provider: ___________________________
Physician: ____________________________________
Phone: _________________________
Emergency Contact: ___________________________
Phone: _________________________
YOUR HEALTH
1. Have you ever had a facial treatment before? __ No __ Yes
2. Which of the following best describes your skin type? (Please circle one type number)
I Creamy complexion
Always burns easily; never tans
II Light complexion
Always burns, tans slightly
III Light/Matte complexion
Burns moderately, tans gradually
IV Matte complexion
Seldom burns, always tans
V Brown complexion
Rarely burns, deep tan
VI Black complexion
Never burns, deeply pigmented
What is your hereditary background? _____________________________________
3. Do you have any special skin problems or concerns pertaining to your face or body?
__No __ Yes Specify: __________________________________________________
4. Have you ever had chemical peels, laser or microdermabrasion? __No __ Yes
In the last month?__No __ Yes
5. Have you been under the care of a physician, dermatologist or other medical professional within the
past year? __No __ Yes Explain: __________________________________________________
6. Any recent surgery, including plastic surgery? __ No __Yes Explain:_________________________
__________________________________________________________________________________
7. Any skin cancer: __ No ___ Yes Explain _______________________________________________
8. Have you had any piercings, tattoos or permanent cosmetics? __ No __ Yes
If yes, where on your person? __________________________________________________
9. Have you recently used any self-tanning lotions, creams or treatments? ___ No ___ Yes Specify:
__________________________________
10. Have you used any of the following hair removal methods in the past six weeks? ___ No ___ Yes
Specify: __________________________________
11. Have you used any of the following hair removal methods in the past six weeks? ___ No ___ Yes
Check all that apply:
Shaving
Waxing Electrolysis Plucking Tweezing Threading Depilatories
12. Have you had any of these health conditions in the past or present? Check all that apply:
___ Cancer
___ Hormone imbalance
___ Systemic disease
___ High Blood pressure
___ Spinal injury
___ Thyroid condition
___ Hysterectomy
___ Diabetes
___ Heart problem
___ Varicose veins
___ Arthritis
___ Asthma
___ Eczema
___ Epilepsy
___ Seizure disorders
___ Fever blisters
___ Headaches (chronic)
___ Hepatitis
___ Herpes
___ Frequent cold sores
___ Immune disorders
___ HIV/AIDS
___ Lupus
___ Metal bone pins or plates
___ Insomnia
___ Keloid scarring
___ Psychological treatment
___ Any active infection
___ Blood clotting abnormalities
___ Phlebitis, blood clots ___ Skin Disease/skin lesions
13. What skin care products are you currently using (list brand if known)
Soap ________________________
Shower Gels ____________________________
Toner ________________________
Body Lotions ____________________________
Mask ________________________
Sunscreen ______________________________
Eye Product ___________________
SPF ___________________________________
Cleanser ______________________
Night Moisturizer/Cream __________________
Day Moisturizer ________________
Other __________________________________
Exfoliator _____________________
Makeup Products ________________________
14. What area of concern do you have regarding your skin? (Please check all that apply and
explain: ________________________________________________________________
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
Breakouts/acne
_____
Uneven skin tone
_____
Blackheads/whiteheads
_____
Sun damage
_____
Excessive oil/shine
_____
Wrinkles/fine lines
_____
Rosacea
_____
Dull/dry skin
_____
Broken capillaries
_____
Flaky skin
_____
Redness/ruddiness
_____
Dehydrated
_____
Sun spots/brown spots
_____
Other __________________________________
Eyes:
Dehydrated _____ Wrinkles _____ Puffiness _____ Dark circles _____ Other ________________
Lips:
Dehydrated _____ Cracked/chapped _____ Other _______________________________
Has your physician discussed concerns about raising your body temperature? __No __ Yes
Explain:
Do you smoke: ___No ___ Yes
Do you follow a restricted diet? ___ No ___ Yes Specify: __________________________________
Do you follow a regular exercise program? ___No ___ Yes
What is your stress level? ___ High ___ Medium ___ Low
List any medications you take regularly: ________________________________________________
_________________________________________________________________________________
Do you use Retin-A. Renova, Adapalene Hydroxyl Acid, Deterin, Glycolic Acid, AHA, Salicylic Acid or
Retinol/Vitamin A derivative products? __ No __ Yes Describe: _____________________________
__________________________________________________________________________________
Have you used any of these products in the last 3 months? ___ No ___ Yes
Have you used an acne medication? __ No __ Yes When? __________ Which drug? ___________
26. Do you form thick or raised scars from cuts or burns? __ No ___ Yes
27. Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin)
or marks after physical trauma? ___ No ___ Yes
28. List your daily consumption of: Water________ Caffeine ________ Alcohol________
29. Do you wear contact lenses? ___ No ___ Yes
30. Have you been exposed to the sun or used a tanning bed in the last 48 hours? ___ No ___Yes
31. How frequently are you exposed to the sun or use a tanning bed? ___ Infrequently ___ Frequently
___ Regularly
32. Do you have any metal implants or wear a pacemaker? ___ No ___ Yes
33. Have you ever experienced claustrophobia? ___ No ___ Yes
34. Do you suffer from sinus problems? ___ No ___ Yes
35. Have you ever had an adverse reaction after using any skin care product? (Please circle all that
apply)
Rash Irritation Peeling
Sun Sensitivity Breakout
36. Have you ever had an allergic reaction to any of the following? (Please circle any that apply and
explain)
Cosmetics Medications Food Animals Sunscreens Iodine Pollen AHAs
Aspirin
Fragrances Shellfish
Latex
Drugs ____________
Other ________________________
If yes, please explain:_______________________________________________________________
FEMALE CLIENTS ONLY
37. Are you taking contraceptives? ___ No ___ Yes Specify: ___________________________________
38. Any recent changes to or from your contraceptive treatment? ___ No ___ Yes
Specify: ___________________________________________________________________________
39. Are you pregnant or trying to become pregnant? ___ No ___ Yes
40. Are you lactating? ___ No ___ Yes
41. Any menopause problems? ___ No ___ Yes Specify:
MALE CLIENTS ONLY
42. What is your current shaving system? ___ Wet Shave ___ Electric
43. Do you experience irritation from shaving? ___ No ___ Yes Ingrown Hairs: ? ___ No ___ Yes
Please use this space to complete answers where space was insufficient (include # of question)
_________________________________________________________________________________
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full
disclosure and that is 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.
____________________________________________ Date ______________________________
Client Signature