Health Intake Form Welcome! Please complete this Intake to the best of your ability both prior to your first session at Sesen Skin Body Wellness and any time your health information has changed. The health and lifestyle topics addressed herein ALL have the potential for affecting your skin or causing interactions with aspects of your treatment at the Sesen. Keep in mind that incorrect or incomplete health records can lead to adverse skin reactions even with the most capable Esthetician. Your Health Intake and Treatment Notes are held in the strictest confidence.Name* First Last Email* PhoneBirthday Month Day Year Please enter as mm/dd/yyyyHow did you hear about us?* Would you like to receive our monthly newsletter?YesNoAddress* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What skin concern has been the most pressing for you in the past 30 days? Please select all of the following that apply to your skin: Blotchy Skin Redness Cold Sores Clogged Pores Brown Spots Acne Scars Acne Breakouts Fine Lines/Wrinkles Broken Capillaries Dry Skin Sensitive Skin Dull Skin What ongoing results would you like to see? Have you used the Prescription Oral Acne Medication ACCUTANE or any other brand of Prescription Oral ISOTRETINOIN in the past 6 months? Yes No In the Past What skincare products and topical prescriptions are you currently using at home? Be sure to include EVERYTHING that you apply to your skin.Click on the plus(+) at the end of the line to add items.ProductNameBrand What oral medications, supplements, and other substances are you currently using?Click on the plus(+) at the end of the line to add items.ProductName Are you currently using any of the following on your skin, even occasionally: Topical C Glycolic Acid or AHA Salicylic Acid or BHA Hydroquinone Topical Antibiotics for acne Hydrocortisone Benzoyl Peroxide Retinoids Please check any of the following that apply to you: Pregnancy Nursing Menopause Hormonal Contraceptives Hormone Replacement Therapy Polycystic Ovarian Syndrome Endocrine Disorders Puberty Hepatitis Dermatitis Metal Implants Pacemaker Please check any of the following that you have had in the past 6 months: Botox Injections Skin Cancer Fillers Cosmetic Surgery Chemical Peels Laser Resurfacing Do you have allergies?YesNoDo you have any injuries, disabilities, areas of trauma or areas of sensitivity that your Esthetician should be aware of or avoid touching in order to keep you safe and comfortable? If yes, please explain:Do you have any additional concerns that were not addressed in this Health Intake? If so, please explain: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 irritations to the skin from the treatments received. Professional Estheticians make many judgment calls during the course of treatment. We are trained to customize office and home treatment plans to maximize the health and beauty of your largest organ. Having an up to date health history enables us to make the safest, best choices as we treat your skin, so that you may enjoy the benefit of our full range of knowledge. I am aware that it is my responsibility to inform the Esthetician of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release Sesen Skin Body Wellness from liability and assume full responsibility thereof. I understand that requests to cancel or reschedule appointments are gladly accommodated with 24 hours notice and that short notice cancellations (less than 24 hours) and no shows will be charged.Signature Reset signature Signature locked. Reset to sign again Please sign using your mouse, or finger if using a touch screen.Date* MM slash DD slash YYYY CAPTCHANameThis field is for validation purposes and should be left unchanged.
