Health History Form

Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred Contact Method *

Phone

Email

Text

HAVE YOU BEEN UNDER THE CARE OF A PHYSICIAN, DERMATOLOGIST OR OTHER MEDICAL PROFESSIONAL WITHIN THE PAST YEAR? *

Yes

No

ANY RECENT SURGERY, INCLUDING PLASTIC SURGERY? *

Yes

No

HAVE YOU HAD ANY SKIN CANCER? *

Yes

No

HAVE YOU HAD ANY RECENT COSMETIC PIERCINGS ON THE FACE, OR PERMANENT MAKE-UP, I.E. MICROBLADING OF EYEBROWS, EYE LINER, ETC. *

Yes

No

HAVE YOU EVER HAD ANY OF THESE HEALTH CONDITIONS IN THE PAST OR PRESENT? (Please check all that apply and provide additional information in the space provided) *

Cancer

Hysterectomy

Arthritis

Eczema

Systemic Disease

Headaches (chronic)

Lupus

Psychologic

Keloid Scarring

Hepatitis

Phlebitis, Blood Clots, Poor Circulation

High Blood Pressure

Any Active Infection

Asthma

Seizure Disorder

Thyroid Condition

Varicose Veins

Fever Blisters

Herpes

Immune Disorders

Skin Lesions or Skin Diseases

Spinal Injury

Epilepsy

Insomnia

Hormone Imbalance

Diabetes

Frequent Cold Sores

HIV/AIDS

Blood Clotting Abnormalities

Metal Bone Pins or Plates

N/A

DO YOU SMOKE? *

Yes

No

DO YOU FOLLOW A REGULAR EXERCISE PROGRAM? *

Yes

No

DO YOU USE RETIN-A, RENOVA, ADAPALENE HYDROXYL ACID, GLYCOLIC ACID, AHA, SALICYLIC ACID, RETINOL/VITAMIN A DERIVATIVE PRODUCTS? *

Yes

No

HAVE YOU USED ANY OF THESE PRODUCTS IN THE LAST 3 MONTHS? *

Yes

No

HAVE YOU USED AN ACNE MEDICATION? *

Yes

No

DO YOU HAVE HYPERPIGMENTATION (DARKENING OF THE SKIN) OR HYPOPIGMENTATION (LIGHTENING OF THE SKIN) OR MARKS AFTER PHYSICAL TRAUMA? *

Yes

No

HAVE YOU EVER HAD ANY ADVERSE REACTION AFTER USING ANY SKIN CARE PRODUCT SUCH AS: RASH, IRRITATION, PEELING, SUN SENSITIVITY OR BREAKOUT? *

Yes

No

Date *

MM

DD

YYYY