Skin Antidotes, LLC

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 of these health conditions in the past or present?* required

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?* 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 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

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?* 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 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 Sunscreens* required

Yes

No

Are you taking oral contraceptives? (female clients only)

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)

Yes

No

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.* required

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.* required

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.* required

Yes