Confidential Client Health History & Consultation Form
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3Confidential Client Health History & Consultation Form
(Please complete all 3 pages)
Date:___________________________
Male__ or Female__
Name:_____________________________________________ Date of Birth:________________
Address:_______________________________________________________________________
Email:_____________________________________ How did you hear of us?_______________
Cell Phone:_________________________________ Home:_____________________________
Physician:_______________________________________ Phone:________________________
Emergency Contact:_______________________________ Phone:________________________
Your Health
1. Have you been under the care of a physician, dermatologist or other medical
professional within the past year? __No __Yes, explain:__________________________
2. List any recent surgery, (last 6 months)________________________________________
3. Any skin cancer? __No __Yes, explain:________________________________________
4. Have you had any piercings, tattoos, or permanent cosmetics __No __Yes, where and
when?__________________________________________________________________
5. Have you 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
__Hormone imbalance
__Systemic disease
__High blood pressure
__Spinal injury
__Thyroid condition
__Hysterectomy
__Diabetes
__Heart problems
__Varicose veins
__Arthritis
__Asthma
__Eczema
__Epilepsy
__Seizure disorder
__Fever blisters
__Headaches (chronic)
__Hepatitis
__Herpes
__Frequent cold sores
__Immune disorders
__HIV/AIDS
__Lupus
__Metal pins/plates
__Phlebitis, blood clots
__Psychological treatment
__Insomnia
__Keloid scarring
__Skin disease/skin lesions
__Active infection
__Claustrophobia
__Sinus problems
__Allergy
Other___________________________________________________________________
6. Do you smoke? __No __Yes
7. Do you have a pacemaker/defibrillator? __No __Yes
8. Do you wear contact lenses? __No __Yes
9. List any medication and over the counter supplements you take regularly: ___________
________________________________________________________________________
________________________________________________________________________
10. Do you have hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening
of the skin) or marks after physical trauma? __No __Yes
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