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Health History Intake Form
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required
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required
Known allergies and reactions:
List current medications, including natural supplements (topical & oral):
Do you have any of the following conditions? Check all that apply.
*
Required
Cancer
Diabetes
Hysterectomy
HIV/AIDS
Psoriasis
Keloid Scarring
Menopause
High/Low Blood Pressure
Claustrophobia
Hormone Imbalance
Hepatitis A/B/C
Rosacea
Cold Sores
Blood Clot Disorder
Eczema
Immune Disorder
Skin Disease/Disorder
Varicose
Veins/Phlebitis
Pacemaker/Defribillator
Thyroid Disorder
Blush/Redden Easily
Depression/Anxiety
Bruise Easily
Lupus
Fibromyalgia
Circulation Disorder
Metal Implants/Pins
Heart Disease
Are you currently under the care of a physician or dermatologist?
*
Yes
No
If yes, explain
Any surgeries within the last 6 months?
*
Yes
No
Any dermal injections/fillers within the last 6 months
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Yes
No
If yes, explain
If yes, explain
Are you using any products that contain Retin –A, Renova, Adapalene Hydroxyl Acid, Differin, Glycolic Acid, AHA/BHA, Salicylic Acid, Lactic Acid, Retinol/Vitamin A, Accutane or any other prescription or over the counter skin product?
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Yes
No
Have you used any of these products in the past 3 months?
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Yes
No
If yes, explain
Have you ever had any allergic reaction to any skin products
*
Yes
No
If yes, explain
In case the case of an emergency, please contact:
Relation
Select One
Client Consent: I understand, have read and completed the Health History truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the practitioner of my current medical or health conditions and to update this history as needed. I understand that the services offered are not a substitute for medical care and any information provided by the practitioner is for educational purposes only and not diagnostically prescriptive in nature. I understand that the information herein is to aid the practitioner in giving better service and is completely confidential. The treatments I receive here are voluntary and I release Porsha Rawlings (Technician) and Inksthetics from any liability and assume full responsibility thereof.
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Your Signature
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