Nourish skin health intake form2-09-14

Name _____________________________________________________Date___________________ Address _____________________________City _________________ Zip_____________________ Email _______________________________ Birthday __________________ Age today? ________ Home Phone ____________________________ Alt/Cell ___________________________________
How did you hear about Nourish Inside & Out? ___________________________________________
What are your top 3 concerns at this time?
1. ___________________________2. __________________________3.______________________
Medical History: Pregnant? R Yes R No Maybe R N/A Breastfeeding? R Yes R No
Current health condition or disease? ____________________________________________________
Current medications: ________________________________________________________________
Past Surgeries: _____________________________________________________________________
Have you ever been diagnosed with cancer? R Yes R No Date of last treatment______________
Allergies (including aspirin & iodine): __________________________________________________
Do you use tobacco products? R Yes R No
Do you use any of these topical
OTC:
____ Benzoyl Peroxide (BP)

Prescription products:

____ Tretinoin (Retin A)

Previous Treatments:
Facials:
R Yes R No Last treatment:_________ Any complications? _______________ R Yes R No Last treatment:_________ Any complications? _______________ R Yes R No Last treatment:_________ Any complications? _______________ R Yes R No Last treatment:_________ Any complications? _______________ R Yes R No Last treatment:_________ Any complications? _______________ ______________________________________________________________________________________
If previously filled out this form: Any changes since last visit? No________ Yes: Please indicates changes on form. Initial Please circle the items below that pertain to you:
Botox/ Restylane/ Collagen injections
History of melanoma or basil cell carcinoma
When exposed to the sun, do you:
____ Always burn, never tan

Skincare: What type of skin do you feel you have? Oily Normal Combination Dry
What is your skin routine? (indicate brands of cleansers, toners, serums, moisturizers, masques, etc.)
1. _______________________________________4.__________________________________________
2. _______________________________________5.__________________________________________
3. _______________________________________6.__________________________________________

Any known food allergies?
R Yes R No _____________________________________________ What is your daily intake of (in cups): ___Water ____Coffee ____Tea ____Soda ____Alcohol_____
Do you sleep well?
R Yes R No How many hours? ______________________________ Any pain, stiffness or swelling?
Do you experience yeast infections? R Yes R No Urinary tract infections? R Yes R No
Hormones:
Are your periods regular?
R Yes R No Painful or symptomatic? R Yes R No
Check apply to you:
R *Currently taking oral contraceptives R *History of taking oral contraceptives R *Previously taken oral contraceptives R *IUD birth control *If taking/taken birth control contraceptives- what kind/brand? __________________________________ I understand that the services offered are not a substitute for medical care, and any information provided by the therapist is for educational purposes only and not diagnostically prescriptive in nature. I understand that the therapist does not diagnose, treat, or prescribe for any illness, aliment or disease. I understand the information herein is to aid the therapist in giving better service and is completely confidential. I understand there are certain risks associated with facial services. I hereby hold the company and its associates harmless and waive any and all liability that may arise from any service or products from Nourish Inside & Out. I have fully disclosed all information required on this form including allergies, medications, any health issues and previously preformed services elsewhere. Client Signature ___________________________________________ Date ________ Parent/Guardian Signature providing Consent & Release (if client is less than 18 years of age.) Signature ___________________________________________ Date ________ Nourish Inside & Out Policies
v A 24 hour notice of appointment cancellation is greatly appreciated, when possible. Life and things happen but this simple courtesy will not go unnoticed by me or the client who is waiting for an appointment to come available. v Arriving on time is important. If you are going to be more than 10 minutes late I will need to make changes to your service to accommodate the time we have left in your appointment. At 15 minutes late we may need to reschedule your appointment. If this is the case a $25 fee will be charged as it is then considered a missed appointment. v In regards to not showing up for your scheduled appointment, or not calling to notify me of your cancellation, I will need to ask for a credit card number to keep on file when you re-book your appointment. There will be a charge for the next missed appointment or non-notification of cancellation. The fee is 50% of the scheduled service. In the case of a pre-paid series of appointments, the missed appointment is forfeited and you will be required to pay 50% of the full value of the singe service fee to re-book that appointment. Additionally, if you have a Gift Certificate there will be a 50% reduction in the value of said certificate. v Gift Certificates are good at full value for 6 months from date of issue (other than conditions stated above regarding missed appointments). After six months a Gift Certificate is valued at 50% of original value. At one year the Gift Certificate will be void and have no value. v Returns: Returns of products (opened or unopened) will be accepted within 14 days. Opened products will be refunded at 50% of value. Unopened will be refunded at full value. No exceptions. v The policies are subject to change. v Nourish Inside & Out reserves the right to refuse service. Signature: _____________________________________ Date: ____________________

Source: http://nourishinsideout.com/wp-content/uploads/2011/07/Nourish-Skin-Health-Intake-Form2-09-14.pdf