New Client Forms

Have you been under the care of a physician, dermatologist or other medical professional within the past year?* required

Yes

No

Any recent surgery, including plastic surgery?* required

Yes

No

Any skin cancer?* required

Yes

No

Have you had any piercings, tattoos, or permanent cosmetics?* required

Yes

No

Have you ever had a body spa treatment before?* required

Yes

No

Have you had any of these health conditions in the past or present?* required

Cancer

Hormone imbalance

Systemic disease

High blood pressure

Spinal injury

Thyroid condition

Hysterectomy

Diabetes

Heart problem

Varicose veins

Arthritis

Asthma

Eczema

Epilepsy

Seizure disorder

Fever blisters

Headaches (chronic)

Hepatitis

Herpes

Frequent cold sores

Immune disorders

HIV/AIDS

Lupus

Metal bone pins or plates

Phlebitis

blood clots

poor circulation

Blood clotting abnormalities

Psychological treatment

Insomnia

Keloid scarring

Skin disease/skin lesions

Any active infection

None of these

Has your physician discussed concerns about raising your body temperature?* required

Yes

No

Do you smoke?* required

Yes

No

Do you follow a restricted diet?* required

Yes

No

Do you follow a regular exercise program?* required

Yes

No

What is your stress level?* required

High

Medium

Low

Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?* required

Yes

No

Have you used any of these products in the last 3 months?* required

Yes

No

Have you used an acne medication?* required

Yes

No

Do you form thick or raised scars from cuts or burns?* required

Yes

No

Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?* required

Yes

No

Do you experience any problems sleeping?* required

Yes

No

Do you wear contact lenses?* required

Yes

No

Have you been exposed to the sun or used a tanning bed in the last 48 hours?* required

Yes

No

How frequently are you exposed to the sun or use a tanning bed?

Infrequently

Frequently

Regularly

Do you have any metal implants or wear a pacemaker?* required

Yes

No

Have you ever experienced claustrophobia?* required

Yes

No

Do you suffer from sinus problems?* required

Yes

No

Have you ever had a rash after using any skin care product?* required

Yes

No

Have you ever had irritation after using any skin care product?* required

Yes

No

Have you ever had peeling after using any skin care product?* required

Yes

No

Have you ever had sun sensitivity after using any skin care product?* required

Yes

No

Have you ever had a breakout after using any skin care product?* required

Yes

No

Have you ever had an allergic reaction to Cosmetics* required

Yes

No

Have you ever had an allergic reaction to Medicine* required

Yes

No

Have you ever had an allergic reaction to Food* required

Yes

No

Have you ever had an allergic reaction to Animals* required

Yes

No

Have you ever had an allergic reaction to Sunscreens* required

Yes

No

Have you ever had an allergic reaction to Iodine* required

Yes

No

Have you ever had an allergic reaction to Pollen* required

Yes

No

Have you ever had an allergic reaction to AHAs* required

Yes

No

Have you ever had an allergic reaction to Fragrance* required

Yes

No

Have you ever had an allergic reaction to Shellfish* required

Yes

No

Have you ever had an allergic reaction to Latex* required

Yes

No

Have you ever had an allergic reaction to Drugs* required

Yes

No

Are you taking oral contraceptives? (female clients only)* required

Yes

No

Any recent changes to or from your contraceptive treatment? (female clients only)* required

Yes

No

Are you pregnant or trying to become pregnant? (female clients only)* required

Yes

No

Are you lactating? (female clients only)* required

Yes

No

Any menopause problems? (female clients only)* required

Yes

No

Sex:* required

Female

Male

Other

Does your job require that you work outdoors?* required

Yes

No

Have you ever had a facial treatment before?* required

Yes

No

Which of the following best describes your skin type?* required

Type I

Type II

Type III

Type IV

Type V

Type VI

Have you ever had chemicals peels, laser treatments, or microdermabrasion?* required

Yes

No

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

Yes

No

Have you used acne medication?* required

Yes

No

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

Yes

No

Have you used any hair removal methods in the past six weeks?* required

Yes

No

If yes, check all that apply

Shaving

Waxing

Electrolysis

Plucking

Tweezing

Stringing

Depilatories

Other

Do you experience irritation from shaving?* required

Yes

No

Do you experience ingrown hairs as a result of hair removal?* required

Yes

No

What areas of concern do you have regarding your: Skin* required

Breakouts/acne

Uneven skin tone

Blackheads/whiteheads

Sun damage

Excessive oil/shine

Wrinkles/fine lines

Rosacea

Dull/dry skin

Broken capillaries

Flaky skin

Redness/ruddiness

Dehydrated

Sun/liver/brown spots

Other

What areas of concern do you have regarding your: Eyes* required

Dehydrated

Wrinkles

Puffiness

Dark circles

Other

What areas of concern do you have regarding your: Lips* required

Dehydrate

Cracked/chapped lips

Other

Have you ever had an allergic reaction to any of the following* required

Cosmetics

AHAs

Medication

Fragrance

Food

Shellfish

Animals

Latex

Sunscreens

Drugs

Iodine

Pollen

Other:

Have you recently used any self-tanning lotions, creams, or treatments?* required

Yes

No

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

Yes

No

Are you taking any oral contraceptives?* required

Yes

No

Have you experienced any recent changes to or from your contraceptives?* required

Yes

No

Are you pregnant or trying to become pregnant?* required

Yes

No

Are you experiencing any menopausal symptoms?* required

Yes

No

Are you currently undergoing any hormone therapy treatments?* required

Yes

No

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

<1 glass

1-3 glasses

4-7 glasses

8+ glasses

How many caffeinated beverages (coffee, tea, soda, etc.) do you consume per day? (Please check one)* required

None

1-2 drinks

3-5 drinks

6+ drinks

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

I don’t drink

1-3 drinks

4-7 drinks

8+ drinks

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

<3 hours

3-5 hours

6-8 hours

8-10 hours

10+ hours

Which foods do you consume on a regular basis?* required

Fruits

Vegetables

Dairy/Eggs

Cheese

Poultry

Fish

Grains/Bread

Processed Sugar

Processed Meats

What does your daily commute look like?* required

Car

Bike

Public Transport

Walk

I don’t commute

How often do you travel on a plane?* required

Never

1-2 times per year

1-2 times per quarter

Every month

Every week

How many hours do you spend in front of a screen or digital device?* required

<3 hours

4-6 hours

7-9 hours

10-12 hours

12+ hours

Do you exercise on a regular basis?* required

Yes

No

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

Yes

No

May I call you at the provided phone number to confirm future appointments?* required

Yes

No

May I contact you via mail/email about future promotions and news?* required

Yes

No

Fitzpatrick Classification:* required

Typo

I Typo II

Typo III

Typo IV

Typo V

Typo VI

Vulgaris:

Yes

No

Cystic:

Yes

No

Chronic:

Yes

No

Rosacea:

Yes

No