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Health History Form
Kathryn Sawers
2024-04-01T15:19:04+00:00
Health History Form
Step
1
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3
33%
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
Facebook
Instagram
TikTok
Reddit
media article
google 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
No
Are you lactating?
Yes
No
Are you currently having or due for your menstrual period?
Yes
No
Are you undergoing medically supervised hormone therapy?
Yes
No
Your Skin
Is this your first professional skin treatment?
Yes
No
What are your top three skin goals?
hydration
improved texture
clear skin
even skin tone
refined pores
firmer skin
sculpted/lifted features
calm skin/ reduced redness
radiance/ glow
Check off all the specific skin concerns/ challenges that you would like to target with your treatment today.
fine lines and wrinkles
dehydration/tightness/flakiness
dullness
pigmentation concerns (brown spots, melasma, post-inflammatory hyperpigmentation/PIH)
redness
loss of firmness and elasticity
acne
comedones (commonly known as blackheads)
dryness
oiliness
eye area concerns: puffiness/ dark circles
other
none of the above / not sure
Please share any further details that you would like your skin therapist to know prior to your visit.
What skin care products are you currently using?
bar soap
cleanser
toner/facial mist
moisturizer
face oil
serum
mask
eye products
exfoliator
primer
foundation
Do you use: Retin-A, Renova, Adapalene or any other prescription skin products?
*
Yes
No
If yes, was it in the last 3 months?
Yes
No
Are you currently using products that contain any of the following ingredients?
hydroxy acids (glycolic, lactic, salicylic etc.)
exfoliating scrubs
vitamin A derivatives (Retinol, Retin-A, Retinyl Palmitate)
Do you use sunscreen daily?
Yes
No
If yes, please specify what SPF you use for both face and body.
Makeup
Body products
bar soap
shower gel
scrubs
oil
body moisturizer
depilatory products
self-tanner
Your Routine
Feel free to share as much detail as possible with us, such as specific products you are using, so we can better analyze your current routine and skincare needs.
Do you use facial tools? eg: gua sha, facial rollers, microneedler, nuface, cleansing brush etc.
Yes
No
If yes, please specify which and how often:
Facial hair removal
If applicable, please indicate your preferred method of facial hair removal.
razor
electric shaver
plucking
waxing
depilatory cream
laser
Have you ever had:
chemical peel
microdermabrasion
laser
intense pulsed light
dermaplaning
microneedling
radio frequency skin tightening
If yes, please specify when you last received this treatment.
Choose which best describes your skin’s response to the sun.
always burns, blisters and peels
often burns, blisters and peels
burns moderately
burns rarely, if at all
never burns
Have you ever been diagnosed with melasma?
Yes
No
Do you have a tendency to flush/ experience skin redness?
Yes
No
Have you ever been diagnosed with rosacea?
Yes
No
Do you ever experience a burning, itching, or stinging sensation on your skin?
Yes
No
Client Waiver
*
I confirm to the best of my knowledge that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. By my signature below, I give consent for esthetic services rendered by Collective Skin Care and its affiliates.
I have been informed and advised of all risks associated with the services and procedures I will be receiving*.
I agree to comply with the instructions provided by the service provider.
*Information about potential risks is provided through Collective Skin Care's online booking system.
Consent
*
I hereby release Collective Skin Care, its affiliates and directors from liability for any injury, loss or damage that may result from any services provided or treatments rendered. This release binds my heirs, successors and assigns.
Cancellation policy and credit authorization release
*
We request 24 hours notice for cancellations or appointment changes. Cancellations within 24 hours of the scheduled service are subject to a charge equal to 100% of the booked appointment.
I understand the cancellation policy and agree to pay any cancellation fees I incur.
Parent / Legal Guardian (required for minors)
First
Last
Consent for Minors
I give permission for my ward to be treated by Collective Skin Care
Comments
This field is for validation purposes and should be left unchanged.
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