SPA Evaluation Form

Allana Davis Beauté + Skin

SKIN CARE EVALUATION
Personal Information
Todays Date

Month Day Year
Full Name *

First Name Last Name
Age
Birth Date

Month Day Year
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Home Phone

Area Code Phone Number
Cell Phone *

Area Code Phone Number
E-mail *
Referred by
Emergency Contact *
Emergency Contact Phone Number *
What are your skin concerns? (Wrinkles, pigmentation, melasma, anti-aging etc)
Do you use Retin-A or Renova or any other chemical or physical exfoliant?? *

Yes No
Brand, Type, How Often
Alpha Hydroxy Acid

Yes No
Do You Have A Reaction To Vitamin C? (Allergic, Inflamed, Painful, Skin Sensitivity, etc)

Yes No
Please describe any adverse reaction from a skin care product, cosmetic or skin care treatment experienced within the 24 months
Have you taken Accutane for acne in the past three months:

Yes No
Medical Information:
Are you allergic to shellfish? *

Yes No
Have you seen a dermatologist in the past five years?

Yes No
Reason for visit
Do you have Eczema, Seborrhea, or Rosacea?

Yes No
Where
What triggers your flushing?
Are there any medical problems we should be aware of (HIV, AIDS)?

Yes No
If so, please list
Do you have claustrophobia *

Yes No
Do you have hormonal imbalance (hormonal acne)

Yes No
Do you take birth control pills

Yes No
Do you use oral or topical antibiotics *

Yes No
List current medications or vitamins you are presently taking and reasons
In the past five years have you had or used?
Acne

Yes No
Canker Sores

Yes No
Cold Sores

Yes No
Dermatitis/Eczema

Yes No
Diabetes

Yes No
Latex Allergies

Yes No
Blood Thinners

Yes No
Glycolic Acids

Yes No
Heart Condition

Yes No
Hemophilia

Yes No
High Blood Pressure

Yes No
Keloid Scars

Yes No
Moles

Yes No
Pacemaker

Yes No
Alpha Hydrozy

Yes No
Female Specific Information
In Menopause

Yes No
Post Menopaise

Yes No
Regular Periods

Yes No
Pregnant

Yes No
Breast Feeding

Yes No
Endocrine Problems

Yes No
Other
Do you smoke

Yes No
How much?
How long?
Do you have problems with healing or scarring?
Are you light sensitive?
Have you experience any recent changes in hair color or thickness?
Tanning or Sun Exposure
Sunbathing
Artificial tanning cream
Tanning Booth
Have you recently vacationed or are you planning a vacation with sun exposure?

Yes No
When
What is your skin complexion?

Light Medium Olive Dark
Is your skin

Dry Oily Combination
Do you have any existing skin conditions

Scaring Pigmentation problems (dark or light patches) Acne Rash Telangiectasia Tattoo Permanent make-up Implants Age Spots
Check the number that best describes your skin's response to sun exposure without SPF protection?

Fitzpatrick I Always burn, never tan Fitzpatrick II Always burn, sometimes tans Fitzpatrick III Sometimes burns, always tans Fitzpatrick IV Always tan, never burns Fitzpatrick V Medium to dark skin (Asian, Hispanic, Indian, etc) FitzpatrickVI Black skin
What do you want to improve most about your skin?
Signature

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Allana Davis Beauté + Skin

Medical Information:

In the past five years have you had or used?

Female Specific Information