Microsoft word - client skin health survey

First Name __________________________ Last Name___________________________ DOB ____________Age _______ Street ___________________________________ City ______________________ State _____________ Zip __________ Phone ______________________________________ Email _________________________________________________ Emergency Contact __________________________________________________________________________________ Physician/Dermatologists _____________________________________________________________________________ What is the reason for your visit today? _________________________________________________________________ What special areas of concern do you have? ______________________________________________________________
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Medical History
Are you currently under a physician’s care for any current skin condition or other problem? Yes No
If yes what? ________________________________________________________________________________________ Taking birth Control Pil s? Yes No If so what type? ___________________________ Are you on Hormone Replacement? Yes No If so what type? _______________________ ______________________ If yes what kind and when? ______________________________________ What is your stress level? Low 1 2 3 4 5 6 7 8 9 10 High How often? ______________________________________________________ How much water do you drink every day? ________________________________________________________________ How many caffeinated and/or alcoholic beverages do you consume? __ per week (caffeine) ___ per week (alcohol) Are you currently using or have you used any of the fol owing? (please circle) If so, when and for how long? _________________________________________________________________________ Are you now using or have you ever used Accutane? Yes Do you have any allergies to any food, drugs or cosmetics? Yes If yes, please list them. ____________________ __________________________________________________________________________________________________ Please circle if you are affected by or have any of the fol owing conditions: Please explain above problems or any other significant issues __________________________________________________________________________________________________________________________________________________ Please List all current medications, herbs and supplements that you are currently taking: Client Skin Assessment
Please Circle what applies to your skin:
Do you have any of the following? (please circle) Do you wear sunscreen? How often and what SPF? ____________________________________ Have you ever had any of the following treatments? (please circle) What products do you currently use? (please circle) I certify that the information above is accurate and true to my knowledge and I wil inform Jeanne Hicks LAc, Estheticianof any changes to my condition immediately. I understand that the information above is to be used to aid Jeanne ingiving better service and is to be completely confidentialSignature Jeanne Hicks LAc, Esthetician
Informed Consent
I, ____________________________________________________ consent to and authorize Jeanne Hicks Lac, Esthetician to perform I have not used a scrub, Retin-A, Retinol A, take home microdermabrasion or glycolic peels in the last 72 hours. ______ (Initial)•The nature and purpose of the treatment has been explained to me, and any questions I may have regarding this procedure has beenexplained to my satisfaction. _______ (Initial)•I understand that with any treatment certain risks are involved and that any complications or side effects from known or unknowncauses could occur. I freely assume these risks. . _______ (Initial)•I have no allergies to Iodine. (Seaweed) . _______ (Initial)•I am not Epileptic and do not have heart or circulation problems. . _______ (Initial)•Possible side effects include, but are not limited to: mild redness, extreme redness, bruising, local swelling, stinging, tenderness, dryskin, flaking, lightening or darkening of the skin, infections, pimples, bumpy appearance, and cold sores. Most side effects aretemporary and generally fade within 72 hours. (Chemical Peels) . _______ (Initial)•If prone to cold sores, see your physician about a prescription for Aycloovair, Zovirax, or take supplements of Olive Leaf, LLysine alongwith Beta Carotene, and Folic Acid daily. . _______ (Initial)•It is recommended to discontinue use of all AHA’s, Glycolics, Retin-A, Renova, or any exfoliating products for up to 72 hours postprocedure. Using hydrating, soothing, antioxidants for healing and ice for swelling and inflammation reduction. No sun exposure ortanning beds for 72 hours and use at least a SPF 15 sunscreen daily when receiving treatments is recommended_______ (Initial)•I agree to adhere to all safety precautions and home skin care program as recommended by Jeanne Hicks LAc, Esthetician_______(Initial)•I am over 18 years of age, or I have a parental consent co-signed below. . ________ (Initial)•I will call to inform Jeanne Hicks LAc, Esthetician of any complications or concerns I may have as soon as they occur. _______ (Initial)•I have been off of Accutane for at least 12 months. . ________ (Initial)•I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of this treatment has been explained to me,along with the risks and hazards involved. Although it is impossible to list every potential risk and complication, I have been informed ofpossible benefits, risks, and complications. I also recognize there are no guaranteed results and that independent results aredependent upon age, skin condition, and lifestyle and that there is the possibility I may require further treatments of the treated areas toobtain the expected results at an additional cost. I have read and understand the post-treatment home care instructions. I understandhow important it is to follow all instructions given to me for post-treatment care. In the event that I may have additional questions orconcerns regarding my treatment or suggested home product/post-treatment care, I will consult Jeanne Hicks LAc, Estheticianimmediately. I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies orprescription drugs or products I am currently ingesting or using topically. I have read and fully understand this agreement and allinformation detailed above. I understand the procedure and accept the risks. All of my questions have been answered to my satisfactionand I consent to the terms of this agreement. I do not hold the esthetician responsible for any of my conditions that were present, butnot disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.
Consent to Treatment of Minor:
By my signature below, I hereby authorize Jeanne Hicks LAc, Esthetician to administer Aesthetic services, to my child or dependent, as
they deem necessary.

Source: http://jeannehickslac.com/wp-content/uploads/2012/08/Client-Skin-Health-Survey.pdf