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Client information &


501 Gateway Drive
Suite 104 Clayton, NC 27520
www.SpaNeoClayton.com 919-550-9355

CLIENT INFORMATION & MEDICAL HISTORY
In order to provide you with the most appropriate treatment, we need you to complete the following
questionnaire. All information is strictly confidential.

PERSONAL HISTORY
Client Name: ________________________________________________
Occupation: _______________________________________ City: ________________ State: ______ Zip Code: _____________
Home Phone: (____) ____________ Work Phone: (____) _________ Cell Phone: (____) ____________
Email Address: ______________________Emergency Contact Name & Phone: ___________________________

MEDICAL HISTORY
Are you currently under the care of a physician or dermatologists?
If yes, for what? ________________________________________________________________________

Do you have any of the following medical conditions? (Please check all that apply)
Have you ever had an allergic reaction to any of the following? (Please check all that apply and describe the reaction you experienced) Others: _______________________________________________________
MEDICATIONS
What oral medications are you presently taking?
Others (Please list) ___________________________________________________________________________ _____________________________________________________________________________________________ Are you using any of these prescribed products? Trentinoin (Retin-A, Micro®, Renova, Avita) Adepalene (Differin) Azelaic Acid (Azelex®, Finacea™) Tazarotene (Tazorac®) Isotretinoin (Accutane) Triluma™ Metrogel Any other antibiotics__________________________________________________________________________ What herbal supplements do you use regularly? ______________________________________________________ HISTORY
Do you or have you had any of the following in the last 14 days?
Do you form thick or raised scars from cuts or burns? Do you have Hyper pigmentation (darkening of the skin) or Hypo pigmentation (lightening of the skin) or marks after physical trauma? No If yes, please describe: _____________________________

FEMALE CLIENTS ONLY
Are you currently having or due for your menstrual period?
Are you pregnant or trying to become pregnant?
SKIN
Which of the following best describes your skin type?
Please check if you are presently using any of the following?
What skin care products are you’re currently using?
Face:
Other: ________________________________________________________________________________ How would you describe your skin? Please specify: _________________________________________________________________________________ What skin conditions do you want to improve? Other ______________________________________________________________________________________
Is there any other necessary information you skin care specialists should know before beginning your treatment? If yes,
explain_______________________________________________________________________________________

I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures. Signature: _________________________________________________ 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. Please check if permission is granted to use before and after pictures of the treatments. I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures. Signature:________________________________________________________Date:____________ 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. Client Signature:________________________________________________________Date:____________ 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. Client Signature:________________________________________________________Date:____________ 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. Client Signature:________________________________________________________Date:____________ 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. Client Signature:________________________________________________________Date:____________ 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. Client Signature:________________________________________________________Date:____________ 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. Client Signature:________________________________________________________Date:____________ 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. Client Signature:________________________________________________________Date:____________ 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. Client Signature:________________________________________________________Date:____________ 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. Client Signature:________________________________________________________Date:____________ 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. Client Signature:________________________________________________________Date:____________ 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. Client Signature:________________________________________________________Date:____________ 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. Client Signature:________________________________________________________Date:____________ 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.

Source: http://e-datasmith.com/uploader/studio243/CLIENT%20NEW%20PATIENT%20INTAKE.pdf

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