Client Health History Form
Personal Information
Full Name
Date of Birth
Phone
Email
Address
Medical History
Do you have or have you had any of the following?
Heart Condition
Diabetes
Epilepsy/Seizures
Allergies
Skin Condition
Other
If yes or other, please explain:
Current Medications
Please list any medications you are currently taking:
Skin and Body Concerns
What are your main goals for today's visit?
Are you currently experiencing any of the following?
Pain/Discomfort
Stress/Anxiety
Fatigue
Acne/Breakouts
Dry Skin
If any, please provide details:
Female Clients
Are you pregnant?
Yes
No
Are you breastfeeding?
Yes
No
Lifestyle
How would you describe your activity level?
Low
Moderate
High
Is there anything else we should be aware of?
Consent & Signature
Signature
Date