Brown Shugar Day Spa: Mobile Day Spa Shop::Client Forms::Confidential Skin Health Survey

CLIENT INFORMATION

FIRST NAME :

LAST NAME :

ADDRESS :

CITY :

STATE:

ZIP CODE :

PHONE:

ALTERNATIVE PHONE:

DATE OF BIRTH:

/ /

EMERGENCY CONTACT:

00/00/0000 ex. 02/04/1978

EMAIL ADDRESS:

REFERRED BY:

CLIENT HISTORY

1, Are you currently within the last year, under a physician's care? Select One: yes no *

2. Have you undergone any surgery in the last month? Select One: yes no *

If yes, specify :

3. Have you had any of these health problems in the past or present? *

4. Do you take any medications or vitamins regulary: Select One: yes no *

Please list them below:

Medications:

Vitamins:

5. Do you or have you: Smoke? Select One: yes no *

Had chemical peels? Select One: yes no *

Use Glycolic or alphahydroxy acids ? Select One: yes no *

Ever used Accutane (the acne drug) ? Select One: yes no *

Follow a restriced diet ? Select One: yes no *

Have regular sleep patterns ? Select One: yes no *

Wear contact lenses ? Select One: yes no *

Have your hair frosted, highlighted, or chemically-lightened ? Select One: yes no *

Have metal implants or pacemaker ? Select One: yes no *

6. What temperature of water do you use to cleanse in? Cool Warm Hot *

7. Do you have any special skin problems pertaining to your face? Select One: yes no *

If yes, specify :

8. What type of skin care products are you currently using? Check all that apply: *

Soap	Masque	Moisturizer
Cleanser	Toner	Scrub/Peel
Other

Specify:

Female Clients ONLY *

9. Are you taking oral contraception?
yes no

10. Are you pregnant or trying to become pregnant?
yes no

11. Are you lactating?
yes no

Male Clients ONLY *

12. What is your current shaving system?
Wet Electric

13. Do you ever experience irritation from shaving?
yes no

14. Do you experience ingrown hair? yes no

To be completed by your skin care therapist: List contra-indication to any treatment:
1.

2.

3.

Oil Secretion

1. Do you experience breakthrough oily shine during the day? Select One: yes no *

2. Do you experience skin break-outs? Select One: yes no *

Moisture Hydration

1. How many glasses of plain water do you consume daily? *

2. Do you take laxatives or diuretics? Select One: yes no *

3. Do you ever experience these conditions on your skin? Check all that apply: *

Flakiness

Tightness

Obvious Dryness

4. If you sunbathe, do you use a sunscreen? yes no * If yes, specify SPF#

Capillary Activity

1. Do you burn easily in moderate sunlight? Select One: yes no *

2. Do you blush easily when nervous? Select One: yes no *

3. Have you ever suffered any sinus problems? Select One: yes no *

Nerve Activity

1. Do you drink caffeinated beverages (coffee, tea, soft drinks)? Select One: yes no *

If yes, how many daily:

2. Do you take any stimulants or slimming tablets? Select One: yes no occasionally *

3. What level do you consider your pain threshold to be? Select One: Low Medium High *

4. Have you ever experienced any claustrophobia? Select One: yes no *

5. What type of massage pressure do you prefer? Select One: Light Firm *

8. Have you ever had a reaction to any of the following? Check all that apply: *

Specify:

I understand that the services offered are not a substitute for medical care and any information provided by the esthetician is for educational purposes only and not diagnostically prescriptive in nature. I understand that the information herein is to aid the esthetician in giving better service and is completely confidential.

By submitting this form, I fully understand and agree to the above.