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Contact
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Name
Date of Birth
ADDRESS
CITY
STATE
ZIP
PHONE
EMAIL
Sex
Male
Female
Does your job require that you work outdoors?
No
YEs
How were you referred to us?
Occupation
What would you like to achieve from your treatment today?
Have you ever had a facial treatment before?
No
Yes
When
Have you ever had a body spa treatment before?
Yes
No
If yes, please specify when and what treatment:
Which of the following best describes your skin type? (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
Yes If yes, please specify:
Have you ever had chemicals peels, laser treatments, or microdermabrasion?
Yes
No
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 and when last used:
Have you used acne medication?
Yes
No
when?
Which medication?
Have you experienced Botox, Restylane, or collagen injections?
Yes
No
If yes, please specify:
What skin care products are you currently using? (List brands if known)
Cleanser
Toner
Day Moisturizer
Night Moisturizer
Exfoliator
Mask
Eye Product
SPF/Sunscreen
Scrubs
Makeup Products
Soap
Shower Gels
Body Lotions
Other
Have you used any hair removal methods in the past six weeks?
Yes
No
Check all that apply
Shaving
Waxing
Electrolysis
Plucking
Tweezing
Stringing
Depilatories
Other
What areas of concern do you have regarding your: Skin (Check all that apply)
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
Eyes (Check all that apply)
Dehydrated
Wrinkles
Puffiness
Dark circles
Other
Lips (Check all the apply)
Dehydrated
Cracked/chapped lips
Other
Have you ever had an allergic reaction to any of the following (Check all that apply)
Yes
No
If yes, please specify
Cosmetics
AHAs
Medication
Fragrance
Food
Shellfish
Animals
Latex
Sunscreens
Drugs
Iodine
Pollen
Other
What SPF do you use on your face?
How often/when?
Have you recently used any self-tanning lotions, creams or treatments?
Yes
No
If yes, please specify
Have you had any recent tanning bed or sun exposure that changed the color of your skin?
Yes
No
If yes, please specify
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?
I don’t drink
1-3 drinks
4-7 drinks
8+ drinks
How many hours of sleep do you get per night?
<3 hours
3-5 hours
6-8 hours
8-10 hours
10+ hours
Which foods do you consume on a regular basis?
Fruits
Vegetables
Dairy/Eggs
Cheese
Poultry
Fish
Grains/Bread
Processed Sugar
Processed Meats
What does your daily commute look like?
Car
Bike
Public Transport
Walk
I don’t commute
How often do you travel on a plane?
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?
<3 hours
4-6 hours
7-9 hours
10-12 hours
12+ hours
Do you exercise on a regular basis?
No
Yes
Do you smoke cigarettes, vape, or consume other tobacco products?
No
Yes
What are your stress levels on a scale from 1 to 5 (1 = low stress, 5 = high stress)?
Are you taking oral contraceptives?
No
Yes
If yes, please specify:
Any recent changes to or from your contraceptive treatments?
No
Yes
If yes, please specify what and when
Are you pregnant or trying to become pregnant?
No
Yes
Are you experiencing any menopausal symptoms?
No
Yes
If yes, please specify
Are you undergoing any hormone replacement therapy treatments?
No
Yes
If yes, please specify
Do you experience irritation from shaving?
No
Yes
If yes, please specify
Do you experience ingrown hairs as a result of hair removal?
No
Yes
May I call you at the provided phone number to confirm future appointments?
No
Yes
May I contact you via mail/email about future promotions and news?
No
Yes
May I contact you via mail/email about future promotions and news?
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/skin care professional from liability and assume full responsibility thereof.
Client Name (Printed)
Client Name (Signature)
Date:
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