Client Consult Form Name * First Name Last Name Contact Number * (###) ### #### Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth Emergency Contact * First Name Last Name Emergency Number * (###) ### #### How did you hear about us? Your Skin Assesment Have you ever had a facial treatment before? Yes / No If so, when? What is your #1 skin challenge? When did this begin for you? What do you hope to achieve from your treatment with me today? Are you under the care of a Dermatologist? Yes No Are you currently using any topical or oral medications? i.e.) Accutane, retinol, topical steroids. Have you had Botox or any other injections? If so, when? Have you ever had a reaction to a skin care product? How would you describe your skin? Please check all that apply: Sensative Normal Dry Dehydrated Oily Reactive Combination Mature Congested Uneven Skin Tone Other Medical History Do you have any allergies? i.e.) seasonal allergies, food, essential oils. Please list any medications you are currently taking: Check any that applies to you: High/Low Blood Pressure Thyroid Disorder Hormonal Disorders Immune System condition (Lupus, chronic fatigue, Hashimoto's) Digestive Disorders (IBS, Crohn's, Colitis) Asthma Diabetes HIV Cancer Do you Smoke High Alcohol Intake Other Any other health conditions I should know about? Ladies Are you... Pregnant Trying to become pregnant Breast feeding Do you have any discomfort around your menstrual cycle? i.e.) Cramps, bloating, mood swings, food cravings, breakouts. Any recent changes in birth control? General Information Stress Level: Low Medium High Extremely High Does your occupation require you to work outdoors? Yes / No If so, for how long each day? How much water intake do you get daily (approx.)? Do you sleep well? Yes / No How many hours? Do you find it hard to fall asleep / stay asleep? What do you do to unwind with your free time? i.e.) Yoga, meditation, nutrition, cooking, exercise (what type and how often). In what parts of your body do you hold the most stress? Do you experience digestive issues such as: Gas and bloating Constipation Diarrhea Other I understand, have read and completed this questionnaire truthfully. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof. I acknowledge and declare that aromatherapy is an alternative treatment which helps to promote and maintain health. It is not meant to take the place of diagnosis or treatment by a qualified medical practitioner. Thank you! If you are visiting us in-person for your appointment, please fill out our Covid-19 screening form prior to your visit. COVID-19 SCREENING FORM Covid Screening Name * First Name Last Name Email * Date * MM DD YYYY As you know, COVID-19 continues to evolve quickly, given this, we are conducting active screening on everyone coming to Woodside Holistic to ensure the safety and wellbeing of everyone. Thank you. What is your vaccination status? All visitors are required to wear masks/coverings when visiting Woodside Holistic. Fully Vaccinated 1st Shot Unvaccinated [Medical Exemption] Do you have any of the following symptoms? * Fever New onset of cough Worsening chronic cough Shortness of breath Difficulty breathing Sore throat Decreased loss of smell or taste Chills Headache Unexplained fatigue/malaise/muscle aches Nausea/vomiting, diarrhea, abdominal pain Pink eye Runny nose or nasal congestion (without other known causes) NO SYMPTOMS Have you traveled outside of Canada in the last 14 days? * Yes No Have you been asked to quarantine for the last 14 days? * Yes No Have you tested positive for Covid-19 or had close contact with a confirmed case of Covid-19 WITHOUT wearing appropriate PPE? * Yes No If you are over 70 years of age or older, do you have any of the following symproms? Delirium Unexplained/increased number of falls Acute functional decline Worsening of chronic conditions NO SYMPTOMS If you have answered YES to any of the questions or refused to answer any questions, you have failed the COVID-19 screening and will need to delay your visit to Woodside Holistic. Please call us at 519-760-2082 if you have questions. Thank you!
