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Aesthetically Yours By Mel

Health History Form

Health History

Aesthetically Yours By Melanie Confidential Client Health History Form

Name *

First

Last

Address *

Date of Birth *

Email *

Phone Number *

Emergency Contact *

Emergency Contact Phone Number *

Physician *

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

Yes
No

If yes please explain:

Have you had any recent surgery, including plastic surgery? *

Yes
No

If yes please explain:

Have you been diagnosed with any skin cancer before? *

Yes
No

If yes please explain:

Do you have any piercings, tattoos or permanent cosmetics? *

Yes
No

If yes please where on the body:

Please check if you have had any of these health conditions in the past or present. *

Cancer
Hormonal Imbalance
Systemic Disease
High Blood Pressure
Spinal Injury
Thyroid Condition
Hysterectomy
Diabetes
Heart Problem
Varicose Veins
Arthritis
Asthma
Eczema
Epilepsy
Seizure disorder
Fever Blisters
Headaches(chronic)
Hepatitis
Herpes
Frequent Cold Sores
Immune Disorder
HIV
Lupus
Metal Bone Pins or Plates
Phlebitis
Blood Clots
Poor Circulation
Insomnia
Keloid Scarring
Skin Disease
Skin Lesions
Active Infection
None of the Above

Do you smoke? *

Yes
No

Do you follow a restricted Diet? *

Yes
No

If yes what type:

Do you follow a regular exercise program? *

Yes
No

What is you stress level? *

High
Medium
Low

Please list any medications that are taken regularly:

List any over the counter medications that are taken regularly: ( including vitamins, minerals, herbal supplements, aspirin, etc.)

Do you use Retin-A, Renova, Adapalene Hydroxyl, Deferin, Glycolic Acid, AHA, Salicylic Acid or any vitamin A derivative products? *

Yes
No

If yes, what is it used for:

Have you used any of these products above in the past 3 months? *

Yes
No

Have you used an acne medication? *

Yes
No

If yes, when and which medication:

List your daily consumption of water: *

List your daily consumption of caffeine: *

List your daily consumption of alcohol: *

List how many hours you typically sleep each night: *

Do you wear contact lenses? *

Yes
No

Have you been exposed to the sun or used a tanning bed in the last 48 hours? *

Yes
No

Do you experience claustrophobia? *

Yes
No

Do you suffer from sinus problems? *

Yes
No

Have you ever had an adverse reaction using any skin care products? *

Rash
Irritation
Peeling
Sun Sensitivity
Breakout
None of the above

Please list any allergies:

FEMALE CLIENTS: Are you using contraceptives?

Yes
No

FEMALE CLIENTS: Are you pregnant or trying to become pregnant?

Yes
No

FEMALE CLIENTS: Are you Lactating?

Yes
No

FEMALE CLIENTS: Are you experiencing menopause symptoms?

Yes
No

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 disclosures. I understand that withholding information or providing misinformation may result in contraindications andor irritation to the skin from treatments received. I am aware that this is my responsibility to inform the Aesthetician or Skin Care Therapist of my surrender medical or health conditions and to update this history. The treatments I receive here are voluntary and I release my service provider from liability and assume full responsibility thereof. *

Agree and acknowledge