SPA Evaluation Form

Personal Information

Todays Date

MonthDayYear

Full Name

First NameLast Name

Age

Birth Date

MonthDayYear

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Cell Phone

E-mail

example@example.com

Referred by

Medical Information:

Have you seen a dermotologist in the past five years?

YesNo

Reason for visit

Physicians Name

Have you had cosmetic surgery

YesNo

When

Type of surgery

Whaty type of skin care products do you use?

Cleanser

YesNo

Brand, Type, How Often

Day Moisturizer

YesNo

Brand, Type, How Often

Night Moisturizer

YesNo

Brand, Type, How Often

Retin A, Renova

YesNo

Brand, Type, How Often

Alpha Hydroxy Acid

YesNo

Brand, Type, How Often

Make up

YesNo

Brand, Type, How Often

SPF

YesNo

Brand, Type, How Often

Please describe any adverse reaction from a skin care product, cosmetic or skin care treatment experienced within the 24 months

Have you taken Accutane for acne in the past three months:

YesNo

Do you have Eczema, Seborrhea, or Rosacea?

YesNo

Where

What triggers your flushing

Are there any medical problems we should be aware of (HIV, AIDS)?

YesNo

If so, please list

When tanning, do you burn easily

YesNo

Do you have hormonal imbalance

YesNo

Do you take birth control pills

YesNo

Do you use Retin-A or Renova

YesNo

Do you use oral or topical antibiotics

YesNo

List antibiotics

List current medications or vitamins you are presently taking and reasons

Previous Surgeries

Serious illnesses, injuries, dates of occurence

In the past five years have you had or used?

Accutane

YesNo

Acne

YesNo

Canker Sores

YesNo

Carcinoma

YesNo

Cold Sores

YesNo

Contact Lenses

YesNo

Dermatitis/Eczema

YesNo

Diabetes

YesNo

Genital Herpes

YesNo

Latex Allergies

YesNo

Blood Thinners

YesNo

Glycolic Acids

YesNo

Hearing Aid

YesNo

Heart Condition

YesNo

Hemoplila

YesNo

Hepatitis

YesNo

High Blood Pressure

YesNo

Keloid Scars

YesNo

Metal Pins in Body

YesNo

Moles

YesNo

Pacemaker

YesNo

Tuberculosis

YesNo

Female Specific Information

In Menopause

YesNo

Post Menopaise

YesNo

Regular Periods

YesNo

Painful Periods

YesNo

Pregnant

YesNo

Breast Feeding

YesNo

Birth Control Pills

YesNo

Hormone Pills

YesNo

Endocrine Problems

YesNo

Hormonal Imbalance

YesNo

Other

Do you smoke

YesNo

How much?

How long?

Do you have problems with healing or scarring?

Are you light sensitive?

Have you experience any recent changes in hair color or thickness?

Have you ever been treated by an endocrinologist?

Please list epilation experience for the items listed below:

Laser removal date

Desired treatment area(s)

Last tanning or sun exposure when)?

Sunbathing

Artificial tanning cream

Tanning Booth

Day to Day activities

Have you recently vacationed or are you planning a vacation with sun exposure?

YesNo

When

What is your skin complexion?

LightMediumOliveDark

Is your skin

DryOilyCombination

Do you have any existing skin conditions

Other:

Check the number that best describes your skin's response to sun exposure without SPF protection?

Fitzpatrick I Always burn, never tanFitzpatrick II Always burn, sometimes tansFitzpatrick III Sometimes burns, always tansFitzpatrick IV Always tan, never burnsFitzpatrick V Medium to dark skin (Asian, Hispanic, Indian, etc)FitzpatrickVI Black skin

What do you want to improve most about your skin?

How did you hear about us and/or the procedure that you're interested in?

Wild Heart Wellness