Spa Skin Analysis Intake Form
Divine Spa and Body
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / 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?
*
Yes
No
Are you or have you taken Accutane?
*
Yes
No
Have you or are currently using Retin A, Reinids, or any other topical exfoliant or acne treatment?
*
Yes
No
Have you had any injections (Botox, fillers, or laser treatments) in the last two weeks?
*
Yes
No
Have you ever had a reaction to any of the following?
*
Food
Nuts
Iodine
Fragrance
Sunscreen
Medicines
Hydroxy acids
NONE
Other
Do you have any allergies? Please list below
*
Are you currently pregnant or breastfeeding?
*
Yes
No
Do you ever experience any of these on your skin?
*
Dryness
Oiliness
Flakiness
Tightness
Do you experience skin breakouts?
*
Yes
No
Do you have any special skin problems pertaining to your face or body? If yes, list below:
*
Have you ever had a facial?
*
Yes
No
Are you currently seeing a dermatologist/physician for on-going skin issues? If yes please explain:
*
Any nut or seed allergies?
*
Yes
No
Are you currently taking any medications? List below:
*
Please check all that apply: Circulatory/Respiratory
*
Asthma
Allergies
Dizziness
Fainting
Heat conditions
High/Low blood pressure
Stroke
Varicose veins
NONE
Other
Please check all that apply: Nervous System
*
Fibromyalgia
Herpes/Shingles
Muscular Dystrophy
Numbness/Tingling
Paralysis
Parkinson’s Disease
Sleep Disorder
NONE
Other
Please check all that apply: Muscular/Skeletal
*
Broken/Fractured bones
Carpal tunnel
Disc problems
Headaches
Neck problems
Osteoporosis
Osteoarthritis
Rheumatoid Arthritis
Spasm/Cramps
Spinal problems
Sprains/Strains
Tendonitis
TMJ jaw pains
NONE
Other
Please check all that apply: Other
*
AIDS/HIV
Cancerq
Depression
Diabetes
pregnant
Recent surgeries
Eczema
Psoriasis
NONE
Other
Today's Date
*
-
Month
-
Day
Year
Date
Signature
*
Submit
Should be Empty: