Gender Male Female
Have you been under the care of a physician, dermatologist, or the other medical professional within the past year?
Any recent Surgery, including plastic surgery? Yes No
Have you had any of the following health conditions in the past or present? Cancer Hormone Imbalance High/low blood pressure Hysterectomy Spinal Injury Diabetes Heart Problem Varicose Veins Arthritis Asthma Epilepsy Headaches Hepatitis Fever Blisters/Cold Sores Immune Disorders HIV/AIDS Poor Circulation Insomnia Skin Diseases/Skin Lesions Eczema Scar Easily
Do you Smoke?
Do you follow a restricted diet?
What is your stress level?
Do you wear contact lenses? Yes No
Have you been exposed to the sun or a tanning be within the last 48 hours? Yes No
Do you use or have you ever used Adapalene Hydroxl Acid, Glycolic Acid, AHA, Accutane, Retin-A, Renova, Deferin, Salicylic Acid or any vitamin A derivative product (Accutane)? Yes No
Have you ever experienced an allergic reaction to any of the following? Cosmetics Medicine Food Sunscreens Iodine AHAs Fragrance Shellfish Latex
Have you ever experienced claustrophobia Yes No
I consent to photos being used for office use.
I consent to photos being used for advertising.
Are you taking any oral contraceptives Yes No
Are you pregnant or trying to become pregnant? Yes No
Are you experiencing any menopause problems? Yes No
I understand, have and fully completed this questionnaire truthfully. I agree that constitutes full disclosure, and that it supersede any previous verbal or written disclosures. While all treatments are recommended to achieve the best possible results, I do understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin form treatments received. I am aware that it is my responsibility to inform the technician of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release Totally Refreshed Steam and Spa and my esthetician from liability and assume full responsibility thereof.
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Document Name: Esthetics
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