Client Questionnaire & Health Conditions
Client's Name
First Name
Last Name
Gender
Male
Female
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about us?
Have you ever received professional skin care treatments?
Please Select
Yes
No
Do you have any of the following conditions? If yes, please select them:
Cancer
Hypertension
Hypotension
Metal Implants
Pacemaker or Defibrillator
Diabetes
Claustrophobia
Heart Disease
Thyroid Disorder
Hysterectomy
Hormonal Imbalance
Epilepsy or Seizures
Blush Easily
HIV AIDS
Hepatitis A/B/C
Migraines/Headaches
Depression/Anxiety
Psoriasis
Rosacea
Eczema
Bruise Easily
Spinal Cord Injury
Immune Disorder
Lupus
Keloid Scarring
Blood Clot Disorder
Skin Disease
Fibromyalgia
Menopause
Circulation Disorder
Varicose Veins
Other
What do you consider your skin type?
Normal
Oily
Dry
Acne
Aging
Combination
Sensitive
Rosacea
Other
How does your skin heal?
Fast
Pigments
Scars
Slow
Other
What is your daily skin care regimen at home?
Please check all that apply.
Pregnant
Postpartum
Neck Pain
Back Pain
Headaches
High Blood Pressure
Bruise Easily
Diabetes
Seizures
Knee/ Leg Pain
Metal Implants
Fibromyalgia
Used Retin-A (diferin gel, tretinoin, accutane) within the past 10 days?
Are you taking any contraceptive pills?
Yes
No
Are you breastfeeding?
Yes
No
Are you wearing any contact lenses?
Yes
No
Are you taking any medications that is related to cosmetic or skin improvement?
Terms & Conditions
I understand that my data will be strictly confidential. This clinic does not sell, share, or resell information. I confirm that all information in this form is true and accurate. I confirm that if I hold some important information and complications happened, the clinic will not be liable. I release this clinic and hold harmless against any claims, expenses, damages, and liabilities.
Client Signature
Clear
Date Signed
-
Month
-
Day
Year
Date
Professional Use Only/ Notes Section
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