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Your Skincare Goals

MEDICAL HISTORY

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

2. Any recent surgery including plastic surgery?
NoYes
Please explain

3. Have you ever had any skin Cancer?
NoYes
Please explain

4. Do you have any piercings, tattoos, or permanent cosmetics?
NoYes
Where on your person?
Please explain

5. Have you had any of the following health conditions in the past or present? ( please
check all that apply
and provide additional information in the space provided)
CancerHormone ImbalanceSystemic DiseaseHigh Blood PressureSpinal InjuryThyroid ConditionPCOSHysterectomyDiabetesHeart DiseaseAsthmaArthritisVaricose VeinsEczemaEpilepsySeizure disorderFever BlistersHeadaches / MigraineHepatitisFrequent Cold SoresImmune DisordersHIV / AIDSLupusMetal Bone Pins / PlatesPhlebitis, Blood Clots, Poor CirculationBlood Clotting AbnormalitiesPsychological TreatmentInsomnaiKeloid ScarringSkin Disease / Skin LesionsAny Active Infection

6. Has your physician discussed concerns about raising your blood pressure?
NoYes
Please explain

7. Do you smoke?
NoYes

8. Do you follow any restricted diet?
NoYes
Please explain

9. Do you exercise regularly?
NoYes

10. What do you consider your stress level?
HighMediumLow

11. Please list any medications, you regularly take including vitamins and health
supplements

12. Do you use retin A, Renova, Adapalene, Hydroxyl Acid, Deferin, Glycolic Acid, AHA,
BHA, Retinol or any
derivative of Retinol?
NoYes
Please explain

13. Have you used any of these products in the past 3 months?
NoYes

14. Have you used any acne medication?
NoYes

15. Do you form thick or raised scars from cuts or burns?
NoYes

16. Do you have hyperpigmentation (darkening of the skin) or hypopigmentation (lightening
of the skin) or
marks left from physical trauma?
NoYes
Please explain

17. Do you experience problems sleeping?
NoYes

18. How many hours of average do you sleep at night?

19. Do you wear contact lenses?
NoYes

20. How often are you exposed to the sun ?
InfrequentlyFrequentlyRegular

21. Do you have any metal pins or wear a pacemaker?
NoYes
which one

22. Have you ever experienced Claustrophobia?
NoYes

23. Do you suffer from any sinus problems?
NoYes

24. Have you ever had any adverse reaction after using a skincare product?
NoYes
RashIrritationPeelingSun SensitivityBreakouts

25. Have you ever had an allergic reaction to any of the following?
NoYes
CosmeticsMedicineFoodAnimalsSunscreenIodinePollenAHAsFragranceShellfishLatexDrugsOthers
If Yes, please explain

FOR FEMALE CLIENTS ONLY!

26. Are you taking any oral contraceptives?
NoYes
Please specify

27. Any recent changes to or from your contraceptive treatment?
NoYes
If so, what and when

28. Are you pregnant or trying to become pregnant?
NoYes

29. Are you lactating?
NoYes

30.Are you experiencing any symptoms of menopause?
NoYes
Please explain

Your favourite aroma:
PeppermintLavenderLemongrassEucalyptusCitrusRosemary

WAIVER:
I understand and have read and completed this questionnaire truthfully. I agree
that this constitutes full disclosure, and that it
superseded and previous written or verbal 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 it is my
responsibility to inform
the esthetician of my current medical and health conditions and to update this history. The treatments I receive are
voluntary
and I release this institution and/ or skin care professional from liability and assume full responsibility
thereof.