Spa Skin Analysis Intake Form

Spa Skin Analysis Intake Form

Divine Spa and Body
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?*
What are your main skin concerns?*
What skincare products are you currently using?*
Do you use glycolic acid or salicylic acid regularly?*

YesNo
Are you or have you taken Accutane?*

YesNo
Have you or are currently using Retin A, Reinids, or any other topical exfoliant or acne treatment?*

YesNo
Have you had any injections (Botox, fillers, or laser treatments) in the last two weeks?*

YesNo
Have you ever had a reaction to any of the following?*

FoodNutsIodineFragranceSunscreenMedicinesHydroxy acidsNONEOther
Do you have any allergies? Please list below*
Are you currently pregnant or breastfeeding?*

YesNo
Do you ever experience any of these on your skin?*

DrynessOilinessFlakinessTightness
Do you experience skin breakouts?*

YesNo
Do you have any special skin problems pertaining to your face or body? If yes, list below:*
Have you ever had a facial?*

YesNo
Are you currently seeing a dermatologist/physician for on-going skin issues? If yes please explain:*
Any nut or seed allergies?*

YesNo
Are you currently taking any medications? List below:*
Please check all that apply: Circulatory/Respiratory*

AsthmaAllergiesDizzinessFaintingHeat conditionsHigh/Low blood pressureStrokeVaricose veinsNONEOther
Please check all that apply: Nervous System*

FibromyalgiaHerpes/ShinglesMuscular DystrophyNumbness/TinglingParalysisParkinson’s DiseaseSleep DisorderNONEOther
Please check all that apply: Muscular/Skeletal*

Broken/Fractured bonesCarpal tunnelDisc problemsHeadachesNeck problemsOsteoporosisOsteoarthritisRheumatoid ArthritisSpasm/CrampsSpinal problemsSprains/StrainsTendonitisTMJ jaw painsNONEOther
Please check all that apply: Other*

AIDS/HIVCancerqDepressionDiabetespregnantRecent surgeriesEczemaPsoriasisNONEOther
Today's Date*

MonthDayYear
Date
Signature*

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