N|M SkinCare Beauty

N|M SkinCare Beauty

Confidential Skin Health Questionnaire
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Email *
example@example.com
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Referred by
What is the reason for your visit today? *
Expectations and History
Which conditions would you like to improve? (Select all that apply) *

Acne Scarring Acne Age Spots Enlarged Pores Fine Lines & Wrinkles Hyperpigmentation (Dark Spots) Broken Capillaries Stretch Marks Surgical/Facial Scars Sun Damage
Have you ever had a facial treatment in the past? *

Yes No
What was your experience?
How would you describe your skin? *

Normal Dry Oily T-Zone (Oily) / Combination Sensitive Sun Damaged Dehydrated
How would you rate your skin when exposed to UVA/UVB rays? *

I. Always burns - Never tans II. Always burns easily - Tans Slightly III. Burns moderately - Tans Gradually IV. Seldom burn - Always Tans Well V. Rarely Burns - Deep Tan VI. Never Burns - Deeply Pigmented
Ethnic Background *

English / Irish Native American African American German / Dutch Hispanic Italian / Mediterranean Asian Russian Polish / Hungarian
Eye Color *

Blue Green Hazel Gray Light Brown Dark Brown
Natural Hair Color *

Blonde Red Black White Light Brown Gray / Silver Medium Brown Dark Brown
Skin Tone *

Pale / White Light Light Olive Medium Olive Dark Olive Brown Black Reddish / Freckles
Do you ever experience? *

Flakiness Tightness Redness Excessive oily shine during day None of the above
What is your present skin regimen? (Choose all that apply) *

Soap & Water only Oil-Based Cleanser Cleanser Toner Vitamin C Serum Exfoliants (AHA's) - Lactic, Glycolic, Mandelic, Citric, Malic (BHA’s) - Salycilic Acid Masque Eye Cream Moisturizer Retinol (Vitamin A) Sunscreen 30+ (every day)
Are you exposed to chemicals, oils, or other caustic substances that may aggravate your skin? *

Yes No
If yes, what are they?
Do you blush easily? *

Yes No
If yes, what are the contributing factors?

Emotions Foods Temperature Changes None of the above
Have you ever had any of the following: (Select all that apply) *

Chemical Peels Microdermabrasion Facial Surgery Cosmetic Surgery Collagen Injections Laser Resurfacing Body Treatments Natural Peels (Enzyme Peels) None of the above
Do you sunbathe or use a tanning bed? *

Yes No
Have you had Botox in the past two weeks? [You must wait at least 2 weeks before a Microneedling Treatment]

Yes No
Have you had Fillers in the past month? [You must wait at least 1-month before a Microneedling Treatment]

Yes No
Have you had a Chemical Peel in the past 2-weeks?

Yes No
Have you had a Laser Resurfacing/Laser Hair Removal Treatment in the past month?

Yes No
Have you taken any antibiotics in the past 2 weeks? *
If yes, what?
Are you under treatment for any current skin condition? *

Yes No
If yes, what?
Do you bruise easily? *

Yes No
Do you get sores/blisters (Herpes Zoster/Shingles? [Please be informed that Chemical Peels can trigger outbreaks] *

Yes No
What medications/hormone replacement/vitamins do you presently take? *
List everything you take please!
Have you ever used (Select all that apply) *

Accutane Retin-A Renova Topical Antibiotics Differin Tazarac Hydroquinone AHA’s (Alpha-Hydroxy-Acids) - [Lactic, Glycolic, Mandelic, Malic, Tartaric, Citric Acid] BHA’s (Beta-Hydroxy-Acids) - [Salicylic Acid] None of the above
If you have used any of the above ingredients, please indicate when and for how long you have used them:
Any personal or family history of skin cancer? *

Yes No
If yes, provide detail:
How would you describe your overall health? *

Excellent Good Fair Poor
Have you had any of the following, past or present?

Acne Allergies Arthritis or Bursitis Breast Implant Cancer Cataracts Low-Cholesterol High-Cholesterol Claustrophobic Diabetes Diarrhea Constipation Eczema Epilepsy Hay Fever Headaches Heart Disease/Conditions Hepatitis HIV/AIDS Infections Lupus Menopausal Metal Implants Pace Maker Phlebitis Serious Injury Sleep Problems Low-Thyroid High-Thyroid Varicose Veins Hormonal Imbalance Psoriasis Vitiligo Hirsutism Irregular Blood Pressure
Do you smoke? *

Yes No
Do you wear contact lenses? *

Yes No
Have you ever had a reaction to (Select all that apply)

Cosmetics Metals Medication Food Fragrance Airborne particles Other allergies (Milk, Apples, Citrus, Grapes, Aloe Vera, Aspirin) None of the above

FOR WOMEN:

YES

Oral contraceptives

Are you trying to get pregnant?

Are you taking hormone replacement?

Do you experience hormone imbalances?

MEN: If you're working a full beard, you don't have to ditch it before your facial.

In fact, the products used during your facial may also benefit your facial hair, making it look shinier and healthier/less dryer.

If you do shave, make sure you do it the 2-3 days before, not the day-of your facial.

If you have ingrown hairs I'd recommend shaving/trimming the beard. By doing so, products can penetrate a lot better and will give also give us the freedom to do more on those areas. Basically, giving you optimized results.

FOR MEN:

YES

Do you experience skin breakouts?

Do you have ingrown hair?

FOR MEN:

Electric Shaver

Razor

Do you shave with

Lifestyle & Diet
Is your stress level *

High Medium Low
Do you normally sleep well? *

Yes No
Do you regularly exercise? *

Yes No
Do you follow any special diet? *

Yes No
What do you consume on a daily basis? (Select all that apply)

Protein Complex Carbohydrates Vegetables & Salads Fruit
Do you have food intolerances? *

Yes No
What food intolerances do you have? (Leave blank if none)
How many cups glasses of water do you consume daily? *
How many cups of caffeine-type beverage (coffee, tea, soft drinks) do you consume daily? *

None 1 cup 2-3 cups 4 or more
In our treatment program, it may be necessary to recommend alterations to or additions in your home care regimen; would that be OK with you? *

Yes No
Your practitioner will recommend the appropriate schedule for future facial treatments or physician referral in order to achieve your skin improvement goals.
Informed Consent Release

Please Read the Information Below
I fully understand all the questions above and have answered them all correctly and honestly.

I understand that the services offered are not a substitute for medical care.

I understand that the skin care professional will completely inform me of what to expect in the course of treatment and will recommend adjustments to my regimen if deemed necessary.

I also am aware that individual results are dependent upon my age, skin condition, and lifestyle.

I agree to actively participate in following appoinment schedules and home care procedures to the best of my ability, so that I may obtain maximum effectiveness. In the event that I may have additional questions or concerns regarding my treatment or suggested home product routine, I will inform my skin care professional immediately.

I grant permission to [NM SkinCare Beauty., LLC] for the use of photograph(s) or videos of any and all kind whatsoever. I understand that I may revoke this authorization at any time by notifying the spa. Images will be stored in a secure location and only authorized staff will have access to them. They will be kept as long as they are relevant and after that time destroyed or archived.

I release and hold harmless the skin care professional [Nehemias Mireles], [NM SkinCare Beauty LLC.], and the staff harmless from any liability for adverse reactions that may results from this treatment.
Signature *

Clear
Polices
I have read and understand all of the foregoing information
1. We require 48-hours notice for cancellations. If you do not cancel within 48-hours you will charged 50% of the service. Cancellation for Monday must be phoned on the Friday before.

2. If you are not satisified with your service or products, please contact your skin care professional within 24-hours after your appoinment so that the situation may be corrected. It is our policy to provide you with the best professional service and products customized for your skin condition.
Date *

Month Day Year
Date
Signature *

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N|M SkinCare Beauty

Expectations and History

Lifestyle & Diet

Informed Consent Release

Polices