Client Health HistoryPlease enable JavaScript in your browser to complete this form.Date *Name *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *Birth Date *Mobile Phone *Is it OK to text you appointment reminders? *YesNoEmergency Contact Name *How do you know this person? Examples: parent, sibling, significant other, friend *Emergency Contact Phone Number *How did you hear about Oly Skin & Wax? Examples: Google, Instagram, Facebook, ThurstonTalk, Friend (be sure to include their name so we may thank them!)Health HistoryHave you received BOTH of your COVID vaccinations? *YesNoHave you received your COVID booster shot? *YesNoHave you been under the care of a physician, dermatologist, or other medical professional within the past year? (copy) *YesNoIf yes, please explainAny recent surgery, including plastic surgery? *YesNoIf yes, please explainAny skin cancer? *YesNoIf yes, please explainHave you had any piercings, tattoos, or permanent cosmetics? *YesNoIf yes, please explainHave you had any of these health conditions in the past or present? (Please check all that apply with additional information below): *CancerSpinal InjuryHeart problem Eczema Headaches (chronic) Immune disorders InsomniaPhlebitis, blood clots, poor circulation Hormone imbalance Thyroid condition Varicose veinsEpilepsy/Seizure disorder HepatitisHIV/AIDSAnxietySystemic disease HysterectomyArthritis Migraines Herpes Metal bone pins or platesDepressionAny skin disease/skin lesionsHigh blood pressure Diabetes Asthma Frequent cold Keloid scarringPsychological treatment Any active infectionOther (explain below)Additional information or other health conditions/concerns not listed above: *Please list ANY allergies you have (including medications, cosmetics/ingredients): *Are you allergic to, or have had a reaction to Latex? *YesNoDon't KnowAre you claustrophobic? *YesNoHave you ever had Botox®, Juvederm®, or other injectables? *YesNoWhat Types?How long ago?What were the area(s) treatedPlease list all medications you are taking (including over-the-counter herbs, vitamins and supplements): *Do you smoke? *YesNoDo you follow a restricted diet? *YesNoDo you follow a regular exercise program? *YesNoWhat is your stress level? *HighMediumLowDo you use Retin-A, Renova, Adapalene Hydroxyl Acid, Differin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products? *YesNoIf yes, please specify and indicate the date it was last used: *Have you used a medically prescribed acne medication? *YesNoWhen? *Which drug? *Do you or have you ever formed thick or raised scars from cuts or burns? *YesNoDo you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma to the skin? *YesNoPlease describe: *How many cups of water do you drink per day? Selected Value: 0How many cups of caffeine do you drink per day? (coffee, tea, soda, energy drinks) Selected Value: 0How many alcoholic drinks do you drink per day? (cocktails, wine, beer) Selected Value: 0Do you experience any problems sleeping? *YesNoHow many hours do you typically sleep each night? Selected Value: 0Do you wear contact lenses? *YesNoDo you suffer from sinus problems? *YesNoHave you been exposed to the sun or used a tanning bed in the last 48 hours? *YesNoHow frequently are you exposed to the sun or use a tanning bed? *InfrequentlyFrequentlyRegularlyDo you have any metal implants or wear a pacemaker? *YesNoWhere? *Other/Explain:Are you on birth control? *YesNoSpecify type: *How long have you been on it? *Are you pregnant or trying to become pregnant? *YesNoAre you lactating? *YesNoAny menopause problems? *YesNoPlease specify: *Is there anything else I should know about you? 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 it is my responsibility to inform Melissa Williams, my esthetician, of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release Melissa Williams/Oly Skin & Wax from liability and assume full responsibility thereof.Client Name *Although every precaution will be taken to ensure your safety and well-being before, during, and after your treatment/procedure, please be aware of the following information and possible risks and indicate that you fully understand what to expect. Please check:Client Signature *Clear SignatureDate *PhoneSubmit