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Health History

This form needs to be filled out prior to your first appointment. If any of this information changes after your first appointment please let me know. This information helps me to better serve you.

Birthday
Month
Day
Year
How would you describe your skin?
How would you rate your skin?
I - Always burns, never tans
II - Always burn easily, tans slightly
III - Burns moderately, tans gradually
IV -Seldom burn, always tans well
V - Rarely burns, deep tan
VI - Never burns, deeply pigmented
Do you ever experience
What is your current skin regimen?
Do you blush easily?
Yes
No
If Yes, what are the contributing factors?
Do you
Have you ever had
Are you currently under treatment for any current skin condition?
Yes
No
How does your skin heal?
Do you bruise easily?
Yes
No
Do you get sores/blisters?
Yes
No
Have you ever used
Do you have a history of cancer?
Yes
No
How would you rate your overall health?
Excellent
Good
Fair
Bad
Do you smoke/Vape?
Yes
No
Do you wear contact lenses?
Yes
No
Do you wear hearing aids?
Yes
No
Do you have any of the following in the past or present?
Have you ever had a reaction to

For those with Female Anatomy

Do any of the following apply to you?

Those with Facial Hair

How do you remove your facial hair?
Do you experience skin breakouts after facial hair removal?
Yes
No
N/A
Do you get Ingrown Hairs after facial hair removal?
Yes
No
N/A

Lifestyle & Diet

What is your stress level?
High
Medium
Low
Do you exercise regularly?
Yes
No
Do you have food intolerances or follow a special diet?
Yes
No
How many cups of caffein-type beverages (coffee, tea, soft drinks, energy drinks) do you drink a day?
0 (only occasional use not daily)
1-3
4+

I fully understand all the questions above and have answered them all correctly and honestly. I understand that the services offered are not a substitute for medical care. I understand that the skin care professional will completely inform me of what to expect in the course of treatment and will recommend adjustments to my regimen if deemed necessary. I also am aware that individual results are dependent upon my age, skin condition, and lifestyle. I agree to actively participate in following appointment schedules and home care procedures to the best of my ability, so that I may obtain maximum effectiveness. In the event that I may have additional questions or concerns regarding my treatment or suggested home product routine, I will inform my skin care professional immediately.


I release and hold harmless the skin care professional, Heather Craven of Skin Envee from any liability for adverse reactions that may result from any treatment I receive.


If you are not satisfied with your products or service, please contact me within 24 hours after your appointment so that the situation may be corrected. It is my policy to provide you with the best professional service and products customized for your skin condition.


I have read and understood all of the foregoing information.

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