Client Health History

Date *

Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Birth Date *

Mobile Phone *

Is it OK to text you appointment reminders? *

Yes
No

Emergency 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 History

Have you received BOTH of your COVID vaccinations? *

Yes
No

Have you received your COVID booster shot? *

Yes
No

Have you been under the care of a physician, dermatologist, or other medical professional within the past year? (copy) *

Yes
No

If yes, please explain

Any recent surgery, including plastic surgery? *

Yes
No

If yes, please explain

Any skin cancer? *

Yes
No

If yes, please explain

Have you had any piercings, tattoos, or permanent cosmetics? *

Yes
No

If yes, please explain

Have you had any of these health conditions in the past or present? (Please check all that apply with additional information 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? *

Yes
No
Don't Know

Are you claustrophobic? *

Yes
No

Have you ever had Botox®, Juvederm®, or other injectables? *

Yes
No

What Types?

How long ago?

What were the area(s) treated

Please list all medications you are taking (including over-the-counter herbs, vitamins and supplements): *

Do you smoke? *

Yes
No

Do you follow a restricted diet? *

Yes
No

Do you follow a regular exercise program? *

Yes
No

What is your stress level? *

High
Medium
Low

Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Differin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products? *

Yes
No

If yes, please specify and indicate the date it was last used: *

Have you used a medically prescribed acne medication? *

Yes
No

When? *

Which drug? *

Do you or have you ever formed thick or raised scars from cuts or burns? *

Yes
No

Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma to the skin? *

Yes
No

Please describe: *

How many cups of water do you drink per day?

Selected Value: 0

How many cups of caffeine do you drink per day? (coffee, tea, soda, energy drinks)

Selected Value: 0

How many alcoholic drinks do you drink per day? (cocktails, wine, beer)

Selected Value: 0

Do you experience any problems sleeping? *

Yes
No

How many hours do you typically sleep each night?

Selected Value: 0

Do you wear contact lenses? *

Yes
No

Do you suffer from sinus problems? *

Yes
No

Have you been exposed to the sun or used a tanning bed in the last 48 hours? *

Yes
No

How frequently are you exposed to the sun or use a tanning bed? *

Infrequently
Frequently
Regularly

Do you have any metal implants or wear a pacemaker? *

Yes
No

Where? *

Other/Explain:

Are you on birth control? *

Yes
No

Specify type: *

How long have you been on it? *

Are you pregnant or trying to become pregnant? *

Yes
No

Are you lactating? *

Yes
No

Any menopause problems? *

Yes
No

Please 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 *

Date *

Melissa Williams

Melissa Williams

Melissa Williams

Health History

Melissa Williams, Master Esthetician