Your Skin Care

Date:

MonthDayYear
Date
Name:
Date of Birth:

MonthDayYear
Date
Address:
Home Phone:
Business Phone:
Cell Phone:
E mail address:*
example@example.com
Married: m No m Yes If yes, anniversary date:
If yes, anniversary date:

MonthDayYear
Date
Employer:
Occupation:
Does your job require that you work outdoors? m No m Yes
Referred by:
What would you like to achieve from your treatment today?
Your Skin Care
Have you ever had a facial treatment before? If so, when?
Have you ever had a body spa treatment before? If so, when?
Massage

YesNo
Salt Glow

YesNo
Seaweed Wrap

YesNo
Moor mud

YesNo
Body scrub

YesNo
Which of the following best describes your skin type?

Always burns easily, never tansAlways burns, tans slightlyBurns moderately, tans graduallySeldom burns, always tans wellRarely burns, deep tanNever burns, deeply pigmented
Do you have any special skin problems or concerns pertaining to your face or body?

NoYes
specify:
Have you ever had chemical peels, laser or microdermabrasion?

NoYes
In the last month?

NoYes
Do you use Retin-A, Ronova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products?

NoYes
describe:
7) Have you used any of these products in the last 3 months? m No m Yes

8) Have you used an acne medication? m No m Yes, when?

Soap Toner Mask Eye Product Cleanser Day Moisturizer Exfoliator Scrubs
Shower Gels Body Lotions Sunscreen

Night Moisturizer/Cream Other Makeup Products

9) What skin care products are you currently using? (List brand where known)

10) Have you recently used any self-tanning lotions, creams or treatments? m No m Yes, specify:

11) Have you used any of the following hair removal methods in the past six weeks? m No m Yes, circle all that apply.
Shaving Waxing Electrolysis Plucking Tweezing Stringing Depilatories

12) What areas of concern do you have regarding your: Skin: (Please check any that apply and explain)

Breakouts/acne o Blackheads/whiteheads o Excessive oil/shine o Rosacea o Broken capillaries o Redness/ruddiness o Sun spot/liver spot/brown spot o

Uneven skin tone Sun damage Wrinkles/fine lines Dull/dry skin Flaky skin Dehydrated o Other
Eyes:
dehydrated o wrinkles o puffiness o dark circles o Other:
Lips:
dehydrated o cracked/chapped lips o Other: 13) Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain) If yes, please explain:

Cosmetics o Medicine o Food o Animals o Sunscreens o Iodine o Pollen o

AHAs o Fragrance o Shellfish o Latex o Drugs o Other

member Associated Skin Care Professionals
How often/when?

14 What SPF do you use on your face?How often/when?
How often/when?
15) What SPF do you use on your body?

16) Have you had any recent tanning bed or sun exposure that changed the color of your skin? m No m Yes
specify:
17) Have you experienced Botox, Restylane or Collagen injections? m No m Yes
Female Clients Only:
18) Are you taking oral contraceptives? m No m Yes

19) Any recent changes to or from your contraceptive treatment? m No m Yes
If so, what and when:
20) Are you pregnant or trying to become pregnant? m No m Yes

21) Are you lactating? m No m Yes

22) Any menopause problems? m No m Yes

23) Are you undergoing any hormone replacement therapy? m No m Yes
Male Clients Only:

24 What is your current shaving system? Wet shave oElectric o
25) Do you experience irritation from shaving? m No m Yes Ingrown hairs? m No m Yes
Please use this space to complete answers where space was insufficient. (Please include the number of the question)
Future Appointments/Contact:

May I call you at your home, work or cell phone number to confirm future appointments? m No m Yes
May I call you at your home, work or cell phone number to confirm future appointments? m No m Yes

May I contact you via mail/email about future promotions and news? m No m Yes
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previ ous 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 profes sional from liability and assume full responsibility thereof.
Client Signature:

Clear
Date:

MonthDayYear
Date
member Associated Skin Care Professionals
Should be Empty:

Your Skin Care

Eyes:

Lips:

Female Clients Only: