Skin Health and Treatment Questionnaire
Name
*
First Name
Last Name
Email
*
example@example.com
Cell Phone Number
*
-
Area Code
Phone Number
Date
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referred by
*
What is your main goal for your treatment?
*
Have you ever had a facial before? If yes, when?
Do you have any special skin problems or concerns pertaining to your face or body?
What other treatment might you be interested in?
Facials
Sugaring hair removal
Nano Pen to stimulate collagen & healing response
Do you smoke? If so, how often?
*
Or do you live with a smoker?
On a scale of 1-10 what is your current level of stress?
*
1 is low and 10 is high.
Do you drink water daily?
How many ounces
Do you take supplements?
herbs or vitamins
Please list any medications you take:
Do you exercise? How often?
When you go out in the sun do you
Always burn
Usually burn
Sometimes burn
Rarely burn
Very rarely burn
never burn
Have you ever been treated for the following: Check all that apply.
Acne
Diabetes
Depression
Skin Cancer
Cold Sores
Skin Disease
High Blood Pressure
Cancer
What are your skin concerns?
*
Acne
Aging
Blemishes
Dryness
Oiliness
Peeling
Pigmentation light
Pigmentation dark
Redness
Rough Texture
Sun Damage
Wrinkles
Do you have an allergies? Yes or No.
*
Please List:
Are you allergic to any ingredients? Yes or No.
*
Please list:
Have you recently seen a dermatologist? Yes or No.
Have you had any recent surgeries, laser procedures, or any strong exfoliation treatments? Yes or no. Please list treatment and when:
Are you using any products that contain any of the following ingredients: Check as many as apply.
*
Glycolic Acid
Latic Acid
Salicylic Acid
Exfoliating Scrubs
Vitamin A Derivatives
Do you have any health issues or skin conditions? Yes or No.
Please list
What facial care products do you use? Check as many that apply.
*
Soap
Cleanser
Toner
Moisturizer
Sunscreen
Masks
Night cream
Eye cream
Exfoliant, scrub or peeling products
How do you feel about essential oils?
*
Favorite product line:
Submit
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