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Alicia Kirch Studio

Beauty Knows No Age. Skincare for women over 40

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Online Health History Form

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Health History Form

Please fill out each section of this form by clicking on the down button for each section. Most fields are required.

New Patient Health History Form

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CLIENT INFORMATION

Full Name *

First

Last

Date of Birth *

Gender *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email Address *

Phone Number *

Occupation

How did you hear about us?

Does your job require you to work outdoors?

Yes
No
Occasionally

Emergency Contact Name *

Emergency Contact Number *

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SKINCARE CONSIDERATION

What would you like to achieve from your treatment today? *

What do you like about your skin? *

If I could help you change something about your skin, what would it be? *

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SKINCARE HISTORY

Have you ever had a facial treatment before? *

Yes
No

If yes, when and what type?

Which of the following best describes your skin type? (Please check one) *

Type I Fair skin tones—Always burns, never tans
Type II Light skin tones—Burns easily, tans slightly
Type III Fair to olive skin tones—Burns moderately, tans moderately
Type IV Light brown skin tones—Burns slightly, tans easily
Type V Dark brown skin tones—Rarely burns, tans easily
Type VI Dark brown to black skin tones—Never burns, tans easily

Have you ever had chemical peels, laser treatments, or microdermabrasion in the last month? *

Yes
No

Do you use Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid, or any other Retinol/vitamin A derivative *

Yes
No

If yes, please specify what and when last used:

Have you used acne medication? *

Yes
No

If yes, which medication and when

Have you experienced Botox, Restylane, or collagen injections? *

Yes
No

If yes, please specify what type and how many weeks/months ago:

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SKINCARE PRODUCTS

Products Used *

Cleanser
Toner
Day Moisturizer
Night Moisturizer
Exfoliator

Products Used

Mask
Eye Product
SPF/Sunscreen
Facial Scrubs
Makeup

List the brands you use, if known:

Soaps *

Soaps used

Body Lotions *

body lotion product/brand

Shower Gels *

Shower gels used

Other

other products not listed here - please specify

FACIAL HAIR REMOVAL

Have you used hair removal methods for your face in the past six weeks? (Check all that apply)

Shaving
Waxing
Electrolysis
Tweezing
Stringing
Depilatories

Other facial hair removal procedures:

OTHER CONCERNS

What areas of concern do you have regarding your: Skin (Check all that apply)

Breakouts/acne
Uneven skin tone
Blackheads/whiteheads
Sun damage
Excessive oil/shine
Wrinkles/fine lines
Rosacea

Other Areas of Concern

Dull/dry skin
Broken capillaries
Flaky skin
Redness/ruddiness
Dehydrated skin
Sun/liver/brown spots
Other

Specify other areas of concern:

ALLERGIC REACTIONS

Have you ever had an allergic reaction to any of the following (Check all that apply)

Cosmetics
AHAs
Medication
Fragrance
Food
Shellfish

Allergic reactions

Animals
Latex
Sunscreens
Drugs
Iodine
Pollen

Specify other allertic reactions you have experienced

TANNING | SUN EXPOSURE

What strength SPF do you use on your face? *

Have you had any recent tanning bed or sun exposure that changed your skin color? *

Yes
No

If yes, please specify:

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LIFESTYLE

How many glasses of water do you drink per day? (Please check one) *

< 1
1 - 3
4 -7
8 or more

How many caffeinated beverages (coffee, tea, soda, etc.) do you consume daily? *

None
1 - 2
3 - 5
6 or more

How many alcoholic beverages do you consume per week? (Please check one) *

I do not drink
1 - 3
4 -7
8 or more

How many hours of sleep do you get per night? (Please check one) *

< 3
3 -5
6 - 8
8 - 10
10 or more

How often do you travel on a plane? *

Never
1-2 times per year
1-2 times per quarter
Every month
Every week or more

Exercise *

Do you exercise regularly?

Do you smoke cigarettes, vape, or consume other tobacco products? *

What are your stress levels on a scale from 1 to 5 (1 = low stress, 5 = high stress)? *

FEMALE CLIENTS

Are you experiencing any menopausal symptoms? *

Yes
No

If yes, please specify:

Are you undergoing any hormone replacement therapy treatments? *

Yes
No

If yes, please specify:

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FULL DISCLOSURE AND AGREEMENT

Please read and sign below. This section is required.

I understand and have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure and supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and irritation to the skin from treatments received. The treatments I receive here are voluntary, and I release this institution and the technician/esthetician/skin care professional from liability and assume full responsibility thereof.

Client Name (Printed):

Client Signature:

Clear Signature

Date

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Email *

Contact Info

Phone:
484.888.8457

Services

Microchanneling
Natural Facelifts
Skincare Treatments & Massage
Contact Alicia

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Testimonials

Alicia’s expertise of working with connective tissue, understanding the anatomy is impressive.
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Rita

I highly recommend Alicia Kirch Studio for anyone looking to enhance their skin care routine and achieve a radiant, youthful complexion.
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Heather

Once you realize massage therapy and skincare treatments are not a luxury but an essential part of physical well-being, half the battle is won.
read more

Sheri

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Microchanneling
Natural Facelifts
Skincare Treatments & Massage
Contact Alicia

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