Esthetics client intake form - Uzima Springs Wellness Center

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Home
About Us
Services
- Massage Therapy
Pricing
LMT’S CE’S on Safari
Downloads
Contacts

English
- English
- Deutsch
- Español

Home
About Us
Services
- Massage Therapy
Pricing
LMT’S CE’S on Safari
Downloads
Contacts

English
- English
- Deutsch
- Español

EN
- EN
- DE
- ES

EN
- EN
- DE
- ES

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Home
About Us
Services
- Massage Therapy
Pricing
LMT’S CE’S on Safari
Downloads
Contacts

– Step 1 of 2

CONFIDENTIAL SKIN HEALTH SURVEY

PLEASE PRINT

Name:

Date of Birth:

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Telephone:

Email Address:

Emergency Contact:

Tel:

Dermatologist Name & Phone Number, if any:

Physician Name & Phone Number:

Occupation:

How Did you hear about us?:

Friend
Flyer
Road Side Sign
Building sign
Internet
Gift Certificate

Section 2

1: Is this your first facial?

Yes
No

2: What is the reason for your visit today?

3: What special areas of concern do you have:

4: Are you presently under a physician’s care for any current skin condition or other problem?

Yes
No

If yes, please explain:

5: Are you pregnant?

Yes
No

If so, how far along?

6: Are you taking birth control or hormone replacement?

Yes

No

If so, what type?

7: Do you wear contact lenses?

Yes.

No

8: Do you Smoke?

Yes

No.

9: Do you often experience Stress?

Yes

No

10: Have you had skin cancer?

Yes

No

If yes when and where

11: Are you now using (or used in the past): Azelex Differin: Renova: Retin-A: Tazara Glycolic acid (AHAs):

First Choice
Second Choice
Third Choice

If so when and for how long?

12: Are you now using (or used in the past) Accutane?

Yes

No

If so, when and how long?

13:Do you have Acne?

Yes

No

If so, where is it present most?

14: Do you experience frequent blemishes?

Yes

No

If so, how frequent and where?

15:Do you have any allergies to cosmetics, foods or drugs?

Yes :

No

If so, please ,list:

Home Care Regimen: Please specify brand and when you use item:

Cleanser:

Scrub:

Toner

Mask:

Moisturizer:

Cream:

Sunscreen:

Other:

Please circle if you are affected by, or have any of the following conditions:

Asthma Hepatitis Metal bone pins or plates Cardiac problems Herpes Pacemaker Eczema High Blood Pressure Psychological Problems Epilepsy Hysterectomy Sinus Problems Fever Blisters Immune Disorders Skin Disease Headaches Lupus Urinary or Kidney Problem Diabetes Low Blood Pressure Cancer

First Choice
Second Choice
Third Choice

16: Are you presently taking any medication or under treatment for conditions listed above?

Yes

No

If so , please list

Please Read & Sign:

Client Signature

Date:

Aesthetician's Signature

Date:

Email

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