Spa Skin Analysis Intake Form

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
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
Please check all that apply: Nervous System *

Fibromyalgia Herpes/Shingles Muscular Dystrophy Numbness/Tingling Paralysis Parkinson’s Disease Sleep Disorder NONE
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
Please check all that apply: Other *

AIDS/HIV Cancerq Depression Diabetes pregnant Recent surgeries Eczema Psoriasis NONE
Today's Date *

Month Day Year
Date
Signature *

Clear
Should be Empty:

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