First name

Last name

City

State

Phone

Sex:

Female

Male

Other

How were you referred to us?

Does your job require you to work outdoors?

Yes

What would you like to achieve from your treatment today?

Your Health

Please Answer all the questions, truthfully into the best of your knowledge

Within the last year, have you been under a dermatologist or other medical physicians care?

Yes

If yes, please specify:

Have you had any health problems in the past or present?

Yes

Have you ever been treated for cancer?

Yes

If yes, please specify:

Are you using any blood/ skin thinning, products, or /and drugs?

Yes

Have you use an acne medication?

Yes

If yes, please specify:

Have you had any recent surgery, including plastic surgery? Have you had any recent surgery, including plastic surgery?

Yes

If yes, please specify:

List any medication supplements, vitamins dirutics, slim why you minh pills, Accutane, etc. that you’re taking regularly

Do you smoke?

Yes

Do you follow a strict diet?

Yes

How many glasses of water do you drink per day? How many glasses of water do you drink per day?

>1 Glass

1-3 Glasses

4-7 Glasses

8+ Glasses

How many caffeinated beverages (coffee, tea, soda, etc) do you consume per day

None

1-2 drinks

3-5 drinks

6+ drinks

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

I don't drink

1-3 drinks

4-7 drinks

8+ more

Do you sunbathe or use tanning beds?

Yes

Do you wear eye contacts?

Yes

Are you claustrophobic?

Yes

Have you ever had a facial treatment before?

Yes

If yes, please specify when:

Have you ever experienced the following conditions on your skin?

Flakiness

Tightness

Obvious dryness

None

Eye Concerns (check all that apply)

Dehydrated

Cracked/ Chapped

None

Other

Have you ever had a chemical peel, micro dermabrasion, laser treatments, or any resurfacing treatments in the last month?

Yes

Have you experienced Botox, Resatylane, or collagen injection?

Yes

Do you have any metal implants, a pacemaker or body piercings?

Yes

Do you use Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid, or any other Retinol/ Vitamin A derivative products?

Yes

If yes, when was last used?

What SPF sunscreen do you use on your face?

Do you burn easily in moderate sunlight?

Yes

Do you suffer from sinus problems?

Yes

Female Clients Only

Are you taking oral contraception?

Yes

N/A

Are you pregnant?

Yes

N/A

Male Clients Only

Do you have any shaving challenges?

Yes

If yes, please specify:

Do you have experience with ingrown hairs as a result of hair removal?

Yes

Questions to discuss every visit

Have you started any new medication since your last visit?

Yes

If yes, please specify:

Confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. 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 the technician/esthetician/skincare professional from liability and assume full responsibility thereof

Signature

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Sex:

Female

Male

Other

How were you referred to us?

Does your job require you to work outdoors?

Yes

What would you like to achieve from your treatment today?

Your Health

Please Answer all the questions, truthfully into the best of your knowledge

Within the last year, have you been under a dermatologist or other medical physicians care?

Yes

If yes, please specify:

Have you had any health problems in the past or present?

Yes

Have you ever been treated for cancer?

Yes

If yes, please specify:

Are you using any blood/ skin thinning, products, or /and drugs?

Yes

Have you use an acne medication?

Yes

If yes, please specify:

Have you had any recent surgery, including plastic surgery? Have you had any recent surgery, including plastic surgery?

Yes

If yes, please specify:

List any medication supplements, vitamins dirutics, slim why you minh pills, Accutane, etc. that you’re taking regularly

Do you smoke?

Yes

Do you follow a strict diet?

Yes

How many glasses of water do you drink per day? How many glasses of water do you drink per day?

>1 Glass

1-3 Glasses

4-7 Glasses

8+ Glasses

How many caffeinated beverages (coffee, tea, soda, etc) do you consume per day

None

1-2 drinks

3-5 drinks

6+ drinks

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

I don't drink

1-3 drinks

4-7 drinks

8+ more

Do you sunbathe or use tanning beds?

Yes

Do you wear eye contacts?

Yes

Are you claustrophobic?

Yes

Have you ever had a facial treatment before?

Yes

If yes, please specify when:

Have you ever experienced the following conditions on your skin?

Flakiness

Tightness

Obvious dryness

None

Eye Concerns (check all that apply)

Dehydrated

Cracked/ Chapped

None

Other

Have you ever had a chemical peel, micro dermabrasion, laser treatments, or any resurfacing treatments in the last month?

Yes

Have you experienced Botox, Resatylane, or collagen injection?

Yes

Do you have any metal implants, a pacemaker or body piercings?

Yes

Do you use Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid, or any other Retinol/ Vitamin A derivative products?

Yes

If yes, when was last used?

What SPF sunscreen do you use on your face?

Do you burn easily in moderate sunlight?

Yes

Do you suffer from sinus problems?

Yes

Female Clients Only

Are you taking oral contraception?

Yes

N/A

Are you pregnant?

Yes

N/A

Male Clients Only

Do you have any shaving challenges?

Yes

If yes, please specify:

Do you have experience with ingrown hairs as a result of hair removal?

Yes

Questions to discuss every visit

Have you started any new medication since your last visit?

Yes

If yes, please specify:

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.