Client Consultation Intake Form

I would love to get to know you & help you reach your skin goals, please fill out in detail your current routine and concerns.

Date of Appointment

Name*

Date of Birth*

Address*

Contact Number*

Email*

Sex*

Female

Male

How were you referred to us?

Occupation*

Does your job require you to work outdoors?

Yes

No

What would you like to achieve from your treatment(s) with Boheme Aesthetics?*

Have you had a facial treatment before?*

Yes

No

If yes, when?

Which of the following best describes your skin? (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

Do you have any special skin problems or concerns pertaining to your face or body?*

Yes

No

If yes, please specify:

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

Yes

No

Was it in the last month?

Yes

No

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

Yes

No

If yes, please specify what & when last used:

Have you received Botox, Restylane, any fillers or collagen injections?

Yes

No

If yes, please specify & when:

What skincare products are you currently using: (check all that apply)*

Referencing previous question, please list brands & products in your current routine (please be specific if known)*

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

What areas of concern do you have : (check all that apply)*

Please list other skin concerns:

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

Please list other known allergies or reactions:

What SPF do you use on your face?*

How often/when?

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

<1 glass

1-3 glasses

4-7 glasses

8+ glasses

How many caffeinated beverages do you consumer per week? (please check on)*

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+ drinks

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

Which foods do you consume on a regular basis?*

What does your daily commute look like?

How often do you travel on a plane?

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

Do you exercise on a regular basis?

Yes

No

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

Yes

No

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

Are you taking oral contraceptives? (female Clients)

Yes

No

Are you pregnant or trying to get pregnant? (female clients)

Yes

No

Are you experiencing menopausal symptoms? (female clients)

Yes

No

Are you undergoing hormone replacement therapy treatments?

Is there anything you'd like to share with your skin therapist/esthetician? (questions or concerns)

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

Yes

No

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

Yes

No

Would you like a "silent treatment"? (minimal talking/education during)

YES

NO

Product education welcome but minimal talking