• Face Reality Client Questionnaire

  •  -

  • Medications

    Please check all medications used in the last 12 months
  • *

  • Medical History

    Please check all that apply
  • *

  • Are you under a dermatologist's care?*

  • Lifestyle Considerations

  • Do you work nights?*
  • Have you ever had any reaction to any products or anything you have put on your face?*
  • Please check any allergies*

  • Do you smoke?*
  • Do you use fabric softener or fabric softener sheets in the dryer?*
  • Do you swim in a chlorinated pool regularly?*
  • Do you work around chemicals, tars, oils, grease or inks?*
  • Are you currently under a lot of stress? (common stress= job loss, new job, wedding, romantic breakup, death in the family or close friend, graduation, difficult home life, long commute, heavily scheduled)*
  • Do you use birth control pills, shots or use an IUD?*
  • Do you use makeup removing wipes?*
  • Do you wax, shave, or remove hair from your face?*

  • Diet

  • Please mark any items you consume once a week or more*

  • Products Currently Using

    Please provide brands and names
  • Please mark all face treatments that you have received in the last 12 months

  • Should be Empty: