Client Health History Form
Name*
Date of Birth*
Gender*
Male
Female
Address*
City*
State*
Zip*
Phone*
E-mail*
Do you have 3 weeks or more of hair growth ?*
Have you had this wax service done before?*
Yes
No
Within the past year, have you been cared for by*
a physician
dermatologist
other medical professional
None
Any recent surgery, including plastic surgery?
Have you had or have any of these conditions?*
Cancer
Hormone imbalance
Systemic disease
High blood pressure
Thyroid condition
Diabetes
Eczema
Headaches (chronic)
Herpes
Immune disorders
Keloid scarring
Skin disease/skin lesions
None
List any medications you take regularly
List any over the counter meds you take regularly
Do you use any of the following products?*
Retin-A
Renova
Adapalene Hydroxyl Acid
Deferin
Glycolic Acid
AHA
Salicylic Acid
Retinol
Vitamin A derivative products
None
Have you used them in the last 3-12 months?
Have you used acne medication? When/ Which drug?
Do you form thick/ raised scars from cuts/ burns?
Check the box if true
Do you have any of these skin conditions?*
Hyper pigmentation (darkening of the skin)
Hypo pigmentation (lightening of the skin)
Marks after physical trauma
None
Ever had these after using skin products/ waxing?*
Sun Sensitivity
Breakout
None
If yes to any, please explain
Have you tanned in the last 24 hours ?
Yes
No
How did you hear about us?*
Comments