Conf Health History | Skinuality LLC

First Name

Last Name

Email

Address

Cell Phone

Business Phone

Physician

Physician Phone

Emergency Contact

If yes, please explain

Emergency Contact Phone

If yes, please explain

Have you had any of these health conditions in the past or present? Please list any health conditions. Examples are but not limited to (i.e. Cancer, Hormone Imbalance, Systemic Disease, High Blood Pressure)

List any medications you take regularly

List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly

Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?

Have you used any of these products in the last 3 months?

Have you used an acne medication? If yes, provide which drug and how often you use it.

Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma

List your daily consumption of Water, Caffeine, & Alcohol. Provide consumption for all three beverages.

Do you experience any problems sleeping?

How many hours do you typically sleep each night?

Have you been exposed to the sun or used a tanning bed in the last 48 hours?

Have you ever had an adverse reaction after using any skin care product? Please choose one of the following: Rash, Irritation, Peeling, Sun Sensitivity, Breakout, or none

Have you ever had an allergic reaction to any of the following? (Cosmetics, Medicine, Food, Animals, Sunscreens, Iodine, Pollen, AHAs, Fragrance, Shellfish, Latex, Drugs, or Other) Please choose and explain

Confidential Health History

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