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Confidential Health History 

By completing this form you are giving me an overview of your current health. This is important as it will help me to treat your skin in the best way. Thank you for your patience!

Have you been under the care of a physician, dermatologist or other medical professional within the past year?
Any skin cancer?
Any recent surgery, including plastic surgery?
Have you had any piercings, tattoos, or permanent cosmetics?
Have you ever had a body spa treatment before?
Has your physician discussed concerns about raising your body temperature?
Do you smoke?
What is your stress level
Do you follow a restricted diet?
Do you form thick or raised scars from cuts or burns?
Do you wear contact lenses?
How frequently are you exposed to the sun or use a tanning bed?
Do you have any metal implants or wear a pacemaker?
Have you ever experienced claustrophobia?
Do you suffer from sinus problems?


Are you taking oral contraceptives?
Any recent changes to or from your contraceptive treatment?
Are you pregnant or trying to become pregnant?
Are you lactating?
Any menopause problems?

I understand, have read and completed this questionnaire 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 esthetician/skin care therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.

Thanks for submitting!

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