Skin Care Intake Form

Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Are you a student?

Yes

No

Have you ever experienced any of the following?

Cancer

High/Low Blood Pressure

Metal Implants/Pins Pacemaker/Defibrillator

Diabetes

Claustrophobia

Heart Disease

Thyroid Disorder

Hysterectomy

Hormone Imbalance

Epilepsy/Seizures Blush/Redden Easily

AIDS/HIV

HepatitisA/B/C

Migraines/Headaches

Depression/Anxiety

Psoriasis

Rosacea

Eczema

Bruise Easily

Spinal Injury

Fever Blisters/Cold Sores

Immune Disorders

Lupus

Keloid Scarring

Blood Clot Disorder

Skin Disease/Disorder

Fibromyalgia

Menopause

Eating Disorder

Circulation Disorder

Other: _______________

Do you smoke?

Yes

No

Do you wear contact lenses? *

Yes

No

Are you on a restricted diet?

Yes

No

Are you under the care of a physician or dermatologist?

No

Yes

Any surgeries or dental work in the past 6 months?

No

Yes

Any dermal injections/fillers within the last 6 month?

No

Yes

(a) Are you using any products that contain Retin-A, Renova, Adapalene Hydroxyl Acid, Differin, Glycolic Acid,AHA/BHA, Salicylic Acid, Lactic Acid, Retinol/Vitamin A, Accutane or any other prescription skin products?

No

Yes

Have you used any of these products in the past 3 months?

No

Yes

Have you ever had any of the following treatments?

Facial

Body Wrap

Body Scrub

LED Waxing

Eyelash/Eyebrow Tinting Microdermabrasion

Chemical Peel

Dermaplaning

Laser Resurfacing

Have you ever had any allergic reaction to any skin products?

No

Yes

Do you wear sunscreen daily?

No

YEs

What temperature water do you cleanse your skin with?

Cold

Warm

Hot

Are you currently or trying to become pregnant?

No

Yes

Are you currently lactating?

Yes

No

Any recent changes to/from your contraceptive treatment?

No

Yes