Client Health History Form Georgian College
ADVERTISEMENT
1
2Spa and Esthetics Clinic
Health History
Prior to receiving treatment, we require an accurate health history to assist us in treating you safely. If
your health status changes in the future please inform the treatment provider.
Last Name: __________________________ First Name: __________________________________
Address: _________________________________________ Date of Birth: M_____D_____Y_____
Home Phone #:_____________ Work Phone #:_____________ Cell Phone #: _________________
Occupation: ________________________
Gender (please circle): Female
Male
Other
Email: ____________________________ May we email you information: Yes ______ No ______
How did you hear about us? _________________________________________________________
What do you hope to accomplish during your treatment? ___________________________________
How do you rate your overall health? ___________________________________________________
Do you have a family physician or nurse practitioner? Yes _____ No _____
If yes Name: ____________________________ Address: __________________________________
Phone: ________________________________ Frequency of Visits: _________________________
Have you had surgery in the past 12 months? Yes _____ No_____
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)
❏ HIV
❏ Anxiety/Mental Health Issue
❏ Hepatitis
❏ Warts
❏ Cancer
❏ Arthritis
❏ Diabetes
❏ Asthma
❏ TB
❏ Shortness of Breath
❏ Heart Condition
❏ Emphysema
❏ Chronic Congestive Heart Failure
❏ Bronchitis
❏ Thyroid
❏ Chronic Cough
❏ Heart Disease
❏ Phlebitis/Varicose Veins
❏ Pace Maker of Similar Device
❏ Hysterectomy
❏ Hypersensitivity
❏ Eczema
❏ Stroke
❏ Psoriasis
❏ High Blood Pressure
❏ Skin Conditions
❏ Low Blood Pressure
❏ Fungus
❏ Herpes
❏ Corns
❏ Infectious Disease
❏ Ingrown Toenails
❏ Epilepsy
❏ Other
Over
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical