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Classic Facials
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Traditional Acupuncture
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Skincare
BOOK ONLINE
Healthy History Form
Kathryn Sawers
2023-02-20T22:40:19+00:00
Health History Form
Step
1
of
5
20%
Skin Health Intake Form
Date
*
MM slash DD slash YYYY
Name
*
First
Last
Gender
Female
Male
Non-Binary
Prefer not to say
Preferred Pronouns
She/Her
He/His
They/Them
Prefer not to say
Age
Sharing your age-range can help us better customize your treatment.
under 18
19-25
26-35
36-45
46-55
55 +
Phone
*
Please provide us with the phone number for which you are most easily reached.
Email
*
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
How did you hear about us?
*
friend/family referral
Varnish
internet search
social media
media article
advertising
Referral
If you have been referred, please let us know by whom so we can thank them.
Your Health
Within the last year have you been under a dermatologist, physician or naturopath’s care?
Yes
No
If yes, please specify.
Please check off any health conditions that apply to you.
*
metal implants, pacemaker, or other electical implanted device
epilepsy
circulatory disorder
heart condition
high blood pressure
low blood pressure
diabetes
cancer
hepatitis
immune disorder
arthritis
nerve damage/loss
other
none of the above
If other, please specify.
Do you have any allergies?
*
Yes
No
If yes, please specify.
List any medications, vitamins, diuretics, slimming pills, Isotretinoin, etc. that you take regularly.
*
Do you follow a restricted diet?
Yes
No
If yes, please specify your restrictions.
Do you smoke?
Yes
No
On average how much water do you consume daily?
On average how many alcoholic beverages do you consume weekly?
On average how many caffeinated beverages do you consume daily? (coffee, tea, soft drinks)
Do you exercise regularly?
Yes
No
If yes, please specify how many times per week.
Do you wear contact lenses?
Yes
No
Do you sunbathe or use tanning beds?
Yes
No
If yes, how often?
Have you experienced claustrophobia?
Yes
No
Hormonal Health
These questions can help us determine sensitivity to aspects of the treatment or possible contraindications to treatment.
Do you use hormonal contraceptive?
Yes
No
If yes, please indicate for how long.
Are you pregnant or trying to become pregnant?
Yes
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