Name

First Name

Last Name

Date of Birth

YYYY

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Occupation

Marital Status

Children

Age

Sex

Are you currently taking birth control?

Do you take hormone replacement?

Are you pregnant?

Are you trying to conceive?

If you've been pregnant before, how were your pregnancies?

What kind of birth control do you use?

Are you lactating

Where are you in your menstrual cycle?

Please list any PMS or Menopausal symptoms

Regularity: Quantity of Flow

Emotions

What is the reason for your visit?

What special areas of concern do you have?

Have you had surgery recently?

What medications are you taking presently and for what condition(s)?

(Medication refers to prescription drugs, herbal supplements, vitamins, etc.)

Do you have any allergies?

(Food, environmental, etc.)

Check any that you experience once or more per week:

Headache

Constipation or loose bowels

Stomach upsets or indigestion

Pains in chest area or heart

Weakness in body

What is your skin type?

If you have facials, how often?

Recently, my skin has been...

Do you have skin irritations, rashes, acne, aczema, etc? Please describe.

Have you ever used or are you currently using:

If yes, please explain.

What skincare products are you currently using?

Do you wear contacts?

If yes, please explain.

How do you sleep?

How often do you exercise?

Do you smoke?

Do you have food intolerances?

How would you describe your level of stress? How do you manage it?

On a scale of 1-10, how is your stress level with work / school / life?

1-3 no stress / 4-7 manageable / 8-10 unmanageable

What is your daily caffeine intake?

(Caffeine refers to coffee, tea, soft drinks, or any other caffeinated beverages.)

What is your daily water intake?

What do you consume on a daily basis?

Fruit

Protein

Complex Carbohydrates

Vegetables

Describe your hunger level.

Reaction to missing meals:

Typical quantity of meals:

Eating speed:

Digestion after eating:

Frequency of bowel movement (BM)

BM tendency towards level of comfort

Weight: I currently feel...

General dietary summary:

What is your overall goal?

How committed are you to achieving results?

I agree to the following:

I have completed the client medical form accurately. I have been candid in revealing any condition that could prohibit this treatment such as cold sores, pregnancy, and use of hormones, recent facial surgery or laser resurfacing, recent use of Retin A or use of Accutane within the last twelve months. I understand that there are no guaranteed results form this treatment. Many variables such as age, sun damage, on going sun exposure, smoking, excessive alcohol intake, climate, diet and water intake, skin thickness and sensitivity. I understand that I may or may not peel and that each case is individual. Regardless of precautions taken, I acknowledge the possibility of an adverse reaction to the peel and accept sole responsibility for any medical care that may become necessary. I will immediately contact the Esthetician performing the treatment of any adverse reactions. I will not scratch, pick, pull at or abrade the treated skin. I understand that direct sun exposure and use of a tanning booths is prohibited during this treatment time, and that a mandatory use of a minimum SPF 15 sun protection daily. I understand that to achieve maximum results the recommended home care routine must be followed. I understand that if I altar the routine or use products not recommended by the skin care professional the results could be altered or inhibitive. I also understand that it may take several treatments to obtain the desired results. I understand that the following side effects or complications can occur: 1. Discomfort, 2. Redness and swelling, 3. Hypopigmentation, 4. Itching or irritation, 5. Skin peeling or flaking up to 14 days after the procedure, 6. Infection, 7. Scarring, 8. Hyperpigmentation, 9. Acne Breakouts. I understand the goals of the treatment as well as the limitations and possible complications. The technician had provided the information and has answered all my questions concerning this procedure. I clearly understand the above information.

Yes

Informed Consent

I UNDERSTAND THAT TREATMENTS GIVEN HERE ARE FOR THE PURPOSE OF STRESS REDUCTION, RELIEF FROM MUSCULAR TENSION OR SPASM, FOR INCREASING CIRCULATION AND CLEANSING THE SKIN. I UNDERSTAND THAT YOUR THERAPISTS DO NOT DIAGNOSE ILLNESS, DISEASE OR ANY OTHER PHYSICAL OR MENTAL DISORDER. AS SUCH YOUR THERAPIST DOES NOT PRESCRIBE MEDICAL TREATMENT OR PHARMACEUTICALS, NOR DO THEY PERFORM ANY SPINAL MANIIPULATIONS. IT IS CLEAR TO ME THAT SPA THERAPIES ARE NOT A SUBSTITUTE FOR MEDICAL EXAMINATIONS AND/OR DIAGNOSES, AND THAT IT IS RECOMMENDED THAT I SEE A PHYSICIAN FOR ANY PHYSICAL AILMENT THAT I MIGHT HAVE BECAUSE A THERAPIST MUST BE AWARE OF EXISTING PHYSICAL CONDITIONS. I HAVE STATED ALL MY KNOWN MEDICAL CONDITIONS AND TAKE IT UPON MYSELF TO KEEP THE THERAPIST UPDATED ON MY PHYSICAL HEALTH. I DO NOT HOLD THE THERAPIST RESPONSIBLE FOR ANYTHING THAT MIGHT OCCUR FROM ANY UNKNOWN AILMENT OR MISINFORMATION. I UNDERSTAND AROMATHERAPY IS A HEALING ART AND SCIENCE THAT SUPPORTS AND ENHANCES THE INDIVIDUAL ABILITY TO HEAL AND MAINTAIN HEALTH. I UNDERSTAND THAT THIS FORM IS DESIGNED TO GATHER INFORMATION SO THAT MY PRACTITIONER IS ABLE TO DESIGN AND CREATE SPECIFIC TREATMENTS AND PRODUCTS BASED ON MY UNIQUE NEEDS AND GOALS. Since essential oils and other ingredients should not be used under certain circumstances, I affirm that I have truthfully answered all questions pertaining to my health on the Medical/Aromatherapy Intake Form. I hold my Aesthetician and Clinical Aromatherapist, Claudia Colombo harmless for any injuries or negative effects I may experience as a result of receiving treatment or using the products I receive from this consultation. Claudia Colombo Skin Wellness upholds strict confidentiality.

Yes

Thank you for your submission!

I will reach out if I find that I need any other information relevant to your upcoming treatment.

New Client Form

Before we begin our journey…