GUEST HEALTH HISTORY FORM In the events of COVID-19, Exhale a Day Spa is taking every precaution to protect our guests and employees. Please enable JavaScript in your browser to complete this form.Name *FirstLastDOB *Email AddressPhone Number *Address *City *Who may we thank for your referral?What is your main concern that we may address during your visit today?What is your current home care regimen?CheckboxesCleanserTonerDaily MoisturizerNight MoisturizerSerum/ConcentrateScrubMaskSun blockOther1. Have you been under the care of a physician for any reason in the past year?YesYesNoIf Yes explain2. Have you had any recent surgeries including plastic surgery in the past year?YesYesNoIf Yes explain3. Please check any of the following conditions you have or may have had in the past:CancerCanker SoresThyroid ConditionEczemaHIV/AIDSKeloid ScarringMetal Implants or ProsthesisHormone ImbalanceHigh Blood PressureEpilepsyLupusAcne ConditionHepatitisHeart ConditionsSeizure DisorderPacemakerSinusHerpes SimplexVaricose VeinsBlood ClotsInsomniaSkin DiseaseAllergies4. Identify your stress levelLowLowMediumHigh5. List all counter medication, herbs or vitamins you take on a daily basis:6. In the past three months have you used any of the following:AccutaneRetin-ARenovaGlycolic AcidSalicylic AcidAHA or Retinol / Vitamin A derived products7. Have you used any type of medication for acne conditions?YesYesNo8. Are you pregnant, trying to get pregnant or lactating?YesYesNo9. Are you taking Oral Contraceptives?YesYesNo10. Are you menopausal, in menopause or post menopausal?YesYesNo11. Do you smoke?YesYesNo12. Are you currently dieting or on exercise program?YesYesNo13a. How much "Water" do you consume in a day?13b. How much "Caffeine" do you consume in a day?13c. How much "Alcohol" do you consume in a day?13d. How much "Diet Soda" do you consume in a day?14. Have you been exposed to the sun or used a tanning bed in the past 24 hours?YesYesNo15. Do you wear contact lenses or glasses?YesYesNo16. Have you ever had an adverse reaction after using any skin care products?YesYesNo17. Have you ever had an allergic reaction to any of the following:CosmeticsCitrusMedicineNutsFoodAnimalsSunscreensIodineAHAPollenFragranceOther18. Have you had skin care treatments in the past?YesYesNo19. It may be necessary to change your current regimen for optimum results, is this ok?NoNoYes20. Do you usually break out after skin care treatments?NoNoYes21. Have you ever experienced unexplained itching, swelling, flaking or redness after a facial?NoNoYes22. Do you use a sun block daily?NoNoYes23. Do you suffer from hyper or hype pigmentation?NoNoYes24. Is there anything that we should know about you that we have not asked that can help us better serve you?Are you experiencing any of the following skin care problems?WhiteheadsIngrown hairFine LinesRosaceaOily complexionMolesAges spot-handsDehydrationWartsPsoriasisBroken CapillariesBlackheadsHypopigmentationEczemaDry ScalpWrinklesHyperpigimentationAcneCelluliteClient Signature (Print your name): *Today's Date *Submit
(808) 762-2169
info@exhaleadayspa.com
1088 Bishop Street Suite #508