Add your info
First and last name*
Birthday*
Mobile number*
Email address*
Date:*
Have you been under the care of a physician, dermatologist or other medical professional within the past year?*
Yes
No
If yes, explain:
Physician:
Physician's Phone Number:
Any recent surgery, including plastic surgery?*
Yes
No
If yes, please explain:
Any skin cancer?*
Yes
No
If yes, please explain further:
Have you had any of these health conditions in the past or present?*
Cancer
Hormone imbalance
Systemic disease
High blood pressure
Thyroid condition
Diabetes
Heart Problem
Varicose Veins
Eczema
Fever blisters
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
Do you smoke?*
Yes
No
Do you follow a restricted diet?*
Yes
No
If you do, please specify:
Do you follow a regular exercise program?*
Yes
No
What is your stress level?*
High
Medium
Low
List any medications you take regularly:
List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?*
Yes
No
If yes, describe:
Have you used any of these products in the last 3 months?*
Yes
No
Have you used an acne medication?*
Yes
No
If yes, when and which drug?
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
Yes
No
If yes, describe further:
List your daily consumption of: Water*
List your daily consumption of: Caffeine*
List your daily consumption of: Alcohol*
Do you experience any problems sleeping?*
Yes
No
How many hours do you typically sleep each night?*
How frequently are you exposed to the sun or use a tanning bed?
Infrequently
Frequently
Regularly
Have you ever had a rash after using any skin care product?*
Yes
No
Have you ever had irritation after using any skin care product?*
Yes
No
Have you ever had peeling after using any skin care product?*
Yes
No
Have you ever had sun sensitivity after using any skin care product?*
Yes
No
Have you ever had an allergic reaction to Cosmetics*
Yes
No
Have you ever had an allergic reaction to Medicine*
Yes
No
Have you ever had an allergic reaction to Sunscreens*
Yes
No
Are you taking oral contraceptives? (female clients only)
Yes
No
Any recent changes to or from your contraceptive treatment? (female clients only)*
Yes
No
If so, what and when? (female clients only)
Are you pregnant or trying to become pregnant? (female clients only)
Yes
No
Please use this space to complete answers where space was insufficient. (Please include the number of the question)
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.*
Yes
I am aware that it is my responsibility to inform the esthetician/skin care therapist of my current medical or health conditions and to update this history.*
Yes
I understand the treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.*
Yes