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Skin Care History Questionaire and Waiver Please answer the fol owing questions so that your Skin Care Specialist may have a better understanding of your general health and lifestyle, thereby enabling your Skin Care Specialist to accurately analyze and assess your skin care needs.
Name: ___________________________________________________________Date: _________________________ Address: _________________________________________________________________________________________ City: _________________________________________________State: ________________ Zip: _________________ Home Phone: __________________________________ Business Phone: _________________________________ Cell Phone: _______________________________Cell Provider: ________ Date of Birth: ________________________________ E-mail address: ______________________________
Health History What type of work do you do? ___________________________________________________________________
Have you seen a dermatologist in the past year? Yes________No________
If yes, list dermatologist’s name, contact info and reason for visit____________________________________
Are you presently under a physician’s care? Yes________No________
If yes, list physician’s name and reason for visit _____________________________________________________
Are you currently taking any medications? Yes________No________ If yes, please list __________________
What is your genetic background? ________________________________________________________________
How is your general health? ______ Excellent ______ Good ______ Fair ______ Poor
Please rate your stress level from 1-5 (5 being the highest): __________
Please circle the following conditions you have or had experienced: •
metal plate •
cold sores •
contact lenses •
irregular pulse •
thyroid disorders •
high cholesterol •
varicose veins •
eating disorder •
heart attack •
tooth fil ings •
high/low blood pressure •
Do you take nutritional supplements? Yes________ No________
Do you exercise? Yes________ No________
Do you have a tendency to scar? Yes________ No________ Allergies:
Check if you have you ever had an allergic reaction to any of the following:
___ASPIRIN OR SALICYLATES ___MILK ___APPLES __CITRUS __GRAPES __LATEX
__INGREDIENTS IN SKIN CARE PRODUCTS __FISH, MARINE OR IODINE ALLERGIES
If checked yes to any of the above, please explain ____________________________________________________________________________________________________________________________________________________________________________________________________
Have you ever had Herpes Simplex? Yes________ No_______
If yes, have you ever been treated with Denavir® (Penciclovir), Zovirax® (Acyclivor) or Abreva?
Are you being treated for Hepatitis? Yes________ No________
Female clients only: Check all that apply.
____Are you on hormone replacement therapy? ___Are you presently taking birth control pills?
Skin Care History Are you currently having skin treatments? Yes________ No________
If yes, what type of treatment(s)___________________________________________________________________
Please check if you are presently using or have used in the past any of the following:
___Benzoyl Peroxide (BP) ___ Glycolic Acid (AHA) ____ Lactic Acid (AHA)
Do you have or have you had any of the following in the last 14 days?
___ Facial Cosmetic Surgery ___ Botox Injections ___Collagen Injections ___ Fillers ___ Light Treatments ___ Laser Resurfacing ____ Microdermabrasion Other ____________________________________________________________________________________________
What Skin care products are you currently using at home?
Cleanser _________________________________ Vitamin C ______________________________________
Toner ____________________________________ Exfoliants/Scrubs ________________________________
Moisturizer ________________________________ Specialty Products ______________________________
SPF _______________________________________ Mask ___________________________________________
___ Tretinoin (Retin A, Retin-A Micro®, Renova, Avita) ____Adepalene (Differin®) ___Azelaic Acid (Azelex®, Finacea™) ___Tazarotene (Tazorac®) ___ Isotretinoin (Accutane) ___ Triluma™ ____ Metrogel Any other topical antibiotics_______________________________________________________________________
PLEASE CHECK IF YOU ARE PRESENTLY EXPERIENCING OR HAVE EXPERIENCED ANY OF THE FOLLOWING:
___ Skin Cancer ___ Dermatitis ___ Keloid Scarring ___Acne ___Rosacea ___ Broken Capillaries ___Treatment Reactions ___Hypopigmentation ___ Hyperpigmentation SUN PROTECTION:
Do you use a sunscreen? Yes________ No________ What level of protection? ________ Do you sunbathe or participate in outdoor activities? Yes________ No________ Do you tan in a tanning booth? Yes________ No________ Have you tanned in a tanning booth in the last 14 days? Yes________ No_________ Have you had any direct sun exposure in the last 10 days? Yes________ No_______
___ Always burn, never tan ___Always burn, sometimes tan ___ Sometimes burn, sometimes tan ____Always tan Do you feel your skin is sensitive? Yes________ No________
WHAT SKIN CONDITIONS DO YOU WANT TO IMPROVE?
___Acne and/or breakouts ____ Facial Scarring ___Hyperpigmentation (freckles, age spots) __ Hypopigmentation ___Enlarged Pores ___ Fine Lines and Wrinkles OTHER ___________________________________________________________________________________________
Is there any other necessary information your Skin Care Specialists should know before beginning your treatment? Yes________ No________
If yes, please explain _____________________________________________________________________________
I have acknowledged that all the information provided by me is true and correct to the best of my
knowledge. I understand that some skin conditions may require more than one treatment and home
care products to achieve the result desired. Results cannot be guaranteed due to individual skin
type(s) and condition(s). I understand I need to sign this waiver prior to every treatment provided,
with ANY changes pertaining to the above questionnaire. I also give permission to use photos for
records and advertising/marketing reasons. I also understand that estheticians performing services at
Bella Pelle Medi Spa are contract workers and carry their own liability insurance. Bella Pelle Medi Spa
is NOT liable for any damage, illness, pain, or suffering caused by any services performed at Bella
Pelle Medi Spa.
Client Signature: __________________________________________Date:_______________________________
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Executive Office of Health and Human Services DEVAL L. PATRICK GOVERNOR TIMOTHY P. MURRAY LIEUTENANT GOVERNOR JUDYANN BIGBY, MD SECRETARY JOHN AUERBACH COMMISSIONER MEMORANDUM Jon Burstein , State EMS Medical Director April 9, 2010 (Update of memorandum dated November 19, 2007) EMT- Basics and Intermediates: Update of Assisted Albuterol Program for Trea