New Client Form for Skin Care and Acne Treatments
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Home Phone Number
-
Area Code
Phone Number
Cell Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
-
Area Code
Phone Number
How did you hear about us?
What would you like to achieve with your treatment today?
Ethnicity
Does your job require you to work outdoors?
Yes
No
Have you ever had a facial treatment before?
Yes
No
If so, when?
-
Month
-
Day
Year
Date
Which of the following best describes your skin type? Just pick one
Creamy complexion: Always burns and never tans
Light complexion: Always burns and tans slightly
Light/medium complexion: Burns moderately, tans gradually
Medium complexion: Seldom burns, always tans well
Brown complexion: Rarely burns, deep tan
Black complexion: Never burns, deeply pigmented
Do you have any special skin problems or concerns pertaining to your face or body?
Have you ever had chemical peels, laser or microdermabrasion?
Yes
No
If yes, was it done within the last month?
Yes
No
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?
Yes
No
Have you used an acne medication?
Yes
No
If so, which drug?
If so, when was it last used?
-
Month
-
Day
Year
Date
What skin care are you currently using? List soap, cleansers, toner, masks, eye products, moisturizers, spf, makeup products, etc.
What areas of concern do you have regarding your skin? Check all that apply
Breakouts/Acne
Blackheads/whiteheads
Excessive oil/shine
Rosacea
Broken capillaries
Redness/ruddiness
Sun spot/liver spot/brown spot
Uneven skin tone
Sun damage
Wrinkles/fine lines
Dull/dry skin
Flaky skin
Dehydrated
What areas of concern do you have regarding your eyes? Check all that apply
Dehydrated
Wrinkles
Puffiness
Dark Circles
Other
What areas of concern do you have regarding your lips? Check all that apply
Dehydrated
Cracked/chapped lips
Other
Have you ever had an allergic reaction to any of the following? Check all that apply
Cosmetics
Medicine
Food
Animals
Sunscreen
Pollen
AHA's
Fragrance
Shellfish
Latex
Other
What SPF do you use on your face? How often and when?
What SPF do you use on your body? How often and when?
Have you had any recent tanning bed or sun exposure that changed the color of your skin?
Yes
No
If yes, please specifiy
Have you experienced Botox, Restylane or Collagen injections?
Yes
No
If yes, please specify
Do you have a pacemaker or other internal metal device?
Yes
No
If yes, please specify
Are you currently taking any medications?
Yes
No
If yes, which?
Female Clients Only (Next set of questions)
Are you taking oral contraceptives?
Yes
No
If yes, please specify
Any recent changes to or from your contraceptive treatment? If so, What and when
Are you pregnant or trying to become pregnant?
Yes
No
Are you lactating?
Yes
No
Any menopause problems?
Yes
No
If yes, please specify
Are you undergoing any hormone replacement therapy?
Yes
No
If yes, please specify
Male Clients Only (Next set of questions)
What is your current shaving system?
Wet shave
Electric
Do you experience irritation from shaving
Yes
No
Acne Clients Only
Current Medications/Drugs (Check all that apply)
Antibiotics
Accutane
Benzoyl Peroxide
Retin A (Cream)
Retin A (Gel)
Tazorac
Differin
Azelex
Avita
Cleocin-T
E-mycin-T
Copaxone
Corticosteroids
Quinine
Androstendione
Testosterone
Progesterone
Thyroid
Gonadotrophin
Danzol
Cyclosporin
Lithium
Immuran
Disulfuram
Dilantin/Tegretol
Steroids
Marijuana
Cocaine/Speed
Medical History (Check all that apply)
Herpes Simplex
Eczema
Psoriasis
Hepatitis
Cancer
Staph Infection/MRSA
HIV/AIDS
Thyroid Problems
Hormone Problems
Hysterectomy
Oophorectomy
Pacemaker
Hemophilia
Lupus
Anemia
High Blood Pressure
Diabetes
Metal Pins in Body
Primary Care Physician's Name
First Name
Last Name
Primary Care Physician's Phone Number
-
Area Code
Phone Number
Are you under a dermatologist or other skin physician's care?
Yes
No
If yes, what is the doctor's name?
First Name
Last Name
Have you ever had a reaction to any products you have put on your face?
Yes
No
If yes, what products?
Are you allergic to any of the following? Check all that apply
Sulfer
Aspirin
Latex
Metal
List any other allergies you know of, if applicable
Do you smoke?
Yes
No
Do you use fabric softener or fabric softener sheets in the dryer?
Yes
No
Do you swim in a chlorinated pool?
Yes
No
Do you work around chemicals, tars, oils, grease, or inks?
Yes
No
What is your occupation?
Do you work nights/overnights?
Yes
No
Are you currently under a lot of stress? Common stressors include job loss, new job, wedding, romantic breakup, death of friend/family member, graduation, difficult home life, long commute, being heavily scheduled
Yes
No
If applicable, do you use birth control pills, shots, or an IUD?
Yes, birth control pills
Yes, shots
Yes, IUD
No
If you use birth control pills, what brand?
Do you regularly consume any of the following foods? Check all that apply
Fast food
Processed food
Salty snacks
Milk/yogurt
Cheese
Whey or soy protein
Peanut butter
Sushi
Kelp/seaweed
Miso soup
Soy
Vitamins
Seafood
What else have you done for your skin in the last 90 days?
Glycolic/Lactic/Mandelic Peels
Other Chemical Peels
Microdermabrasion
Dermabrasion
Laser Hair Removal
Laser Rejuvenation/Resurfacing
Skin Cancer Removal
Facial Waxing
Electrolysis
Conclusion
May I call you at the phone number you provided to confirm future appointments?
Yes
No
May I contact you via mail/email about future promotions and news?
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. 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 skin care professional from liability and assume full responsibility thereof.
I Agree
*After you hit the submit button below, you will need to schedule your first appointment (Consultation with first treatment at confidently-u.com)
Already booked
I understand it's the next step
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