Confidential Health History Form Today's Date * MM DD YYYY Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth * MM DD YYYY Phone * (###) ### #### Email * Physician Physician's Phone Number (###) ### #### Emergency Contact Emergency Contact Phone (###) ### #### YOUR HEALTH Please list all medical conditions below: * Please list all current medications below: * (Including birth control, herbal supplements, vitamins, aspirin, etc.) Please list all allergies * Have you been under the care of a physician,dematologist, or other medical professional wighin the past year? Yes No If yes, please explain Any recent surgery, including plastic surgery? Yes No If yes, please explain Any skin cancer? Yes No If yes, please explain Any piecrcings, tattoos, or permanent cosmetics? Yes No If yes, where on your person? Has you physician discussed concerned about raising your body temperature? Yes No Do you smoke? Yes No Are you following a restricted diet? Yes No Please specify Do you exercise regularly? Yes No What is your stress level? High Medium Low Have you used any acne medication? Yes No If yes, please specify Do you use resin-A, Renova, Adapalene Hydroxyl Acid, Deferring, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products? Yes No If yes, please specify Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma? Yes No If yes, please specify Daily consumption of water: On average, how many cups or ounces? Daily consumption of caffeine: On average, how many cups or ounces? Do you experience any porblems sleeping? Yes No How many hours do 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 How frequently are you expsosed to the sun or use a tanning bed? Infrequently Frequently Regularly Do you have any metal implants or wear a pacemaker? Yes No Have you ever experienced claustrophobia? Yes No Do you suffer from sinus problems? Yes No Have you ever had an adverse reaction after using any skin care product? Such as Rash, Irritation, Peeling, Sun Sensitivity, or Breakout Have you ever had an allergic reaction to any of the following? Cosmetics, Medicine, Food, Animals, Sunscreens, Iodine, Pollen, AHA, Fragrance, Shellfish, Latex, Drugs, or Other? Are you taking oral contraceptives? Yes No Are you pregnant or trying to become pregnant? Yes No Are you lactating? Yes No Any menopause problems? Yes No If yes, please specify Please use this space for any other information you want me to know regarding your health prior to your visit. I understand, have read and completed this aquestionnaire 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 contraindication s and/or irritation to the skin from treatments received. I am awre that it is my responsibility to inform the esthetician/skin care therapist of my currenet medical or health conditions and to update this history. The treatments I recieve here are voluntary and I release this institutuion and/or skin care professional from liability and assume full responsibility thereof. * I agree Electronic Signature * (First and Last Name) Date MM DD YYYY Thank you. Your privacy is very important. This information will never be shared and will only be viewed by your provider.