Skin Care History Questionnaire Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Preferred Phone Number(Required)Mobile/Work/Home(Required)MobileWorkHomeEmail(Required) Sex(Required)MaleFemaleEthnicity(Required) Have you or are you presently using:(Required) Retin A/Renova Glycolic Acid/Alpha Hydroxyl Acid Accutane Topical Vitamin C Hydroquinone Tetracycline Sulfur No, I am not using any of the medications listed above. Have/do you have any:(Required) High Blood Pressure Hepatitis Herpes Skin Cancer HIV/Aids Keloid Scarring Thyroid Disorders Claustrophobia No, I do not have any of the above listed conditions. Any other prescribed skin products? Other Medical Problems: Please answer the following: Do you...(Required) Smoke Drink Caffine Sunbathe Outdoors Sunbathe Indoors Take Nutritional Supplements Have A Special Diet Exercise Wear Contact Lenses Wear Sunscreen When Outdoors Have you ever recieved...(Required) Skin treatments/facials before Professional hair removal Permanent Cosmetics Chemical Peels Laser Resurfacing Botox Injections Cosmetic Surgery Do You Have Epilepsy? Metal Implants or Pacemaker See a Dermatologist?(Required)YesNoFor: See a Physician?(Required)YesNoFor: List Current Medications:Are you currently pregnant or breastfeeding?(Required)YesNoPlease select any conditions in which you would like to improve:(Required) Hyperpigmentation (brown spots) Hypopigmentation (light spots) Sun Damage Facial Scarring Acne/Breakouts Age Spots Blackheads Enlarged pores Fine lines/wrinkles Texture Other Other: What is your normal skin type?(Required) Oily Dry Combination Sensitive What skin care products are you currently using? Please list any allergies you're aware of or reactions you've had to products in the past:(Required)Any other information we should know before beginning your treatment:How much water do you drink per day? By signing this form:(Required)I understand that the esthetician does not diagnose illness, disease, or any physical or mental disorders. I understand that services received are not a substitute for medical treatment, and that it is recommended I see a primary health care provider or dermatologist. I have listed all medical conditions that I am aware of and I will update my therapist of any changes. I am aware of and agree to The Healthy Touch Day Spa’s late cancellation/no show policy.PhoneThis field is for validation purposes and should be left unchanged.
