Face Reality Client Questionnaire

Face Reality Client Questionnaire
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Please share about your experiences with your skin, results you are looking to achieve and any other information you'd like me to know! (ex: How long have you been struggling with breakouts? What have you tried to treat your breakouts?)
Medications

Please check all medications used in the last 12 months
AntiboticsAccutaneBenzoyl PeroxideRetin ATazoracDifferinAzelexAvitaCleocin-TE-mycin-TCopaxoneCorticosteriodsQuinineAndrostendioneTestosteroneProgesteroneThyroidGonadotrophinDanzolCyclosporinLithiumIsoniazidImmuranDisulfuramDilantin/TegretolSteroidsMarijuanaCocaine/SpeedOther
Medical History

Please check all that apply
Herpes SimplexEczemaPsoriasisHepatitisCancerStaph Infection/MRSAHIV/AIDSThyroid ProblemsHormone ProblemsHysterectomyOvary(ies) RemovedPacemakerHemophiliaLupusAnemiaHigh Blood PressureDiabetesMetal in BodyOther
Are you under a dermatologist's care?*

YesNo
Lifestyle Considerations
Age*
Ethnicity *
Occupation*
Do you work nights?*

YesNo
Have you ever had any reaction to any products or anything you have put on your face?*

YesNo
If yes, what products?
Please check any allergies*

SulfurAspirinLatexNoneOther
Do you smoke?*

YesNo
Do you use fabric softener or fabric softener sheets in the dryer?*

YesNo
Do you swim in a chlorinated pool regularly?*

YesNo
Do you work around chemicals, tars, oils, grease or inks?*

YesNo
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)*

YesNo
Do you use birth control pills, shots or use an IUD?*

YesNo
If yes, what method and brand do you use?
Do you use makeup removing wipes?*

YesNo
Do you wax, shave, or remove hair from your face?*

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

Fast FoodProcessed FoodSalty SnacksMilk/YogurtCheeseWhey or Soy ProteinPeanut ButterPeanutsSushiKelp or SeaweedMiso SoupSoyVitaminsSeafoodNone of the above
Products Currently Using

Please provide brands and names
Cleansers
Toners
Serums
Moisturizers
SPF
Masks
Exfoliants (scrubs or acids)
Acne Medications
Makeup Primer
Foundation
Concealer
Bronzer/Blush
Please mark all face treatments that you have received in the last 12 months

Chemical PeelsMicrodermabrasionLaser Hair RemovalLaser Rejuvenation/ResurfacingSkin Cancer RemovalOther
Anything else?
Should be Empty:

Face Reality Client Questionnaire

Medications

Medical History

Lifestyle Considerations

Diet

Products Currently Using