ADS Evaluation Form

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

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 Retinol, Retin-A or Renova or any other chemical or physical exfoliant? (Please discontinue use off these products 1 week before your treatment) *

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

Have you used Benzyl Peroxide:

Yes No No, I’am allergic

Medical Information:

Are you allergic to shellfish? *

Yes No

Have you seen a dermatologist in the past five years?

Yes No

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

Do you smoke

Yes No

Canker Sores

Yes No

Cold Sores

Yes No

Moles

Yes No

Keloid Scars

Yes No

Dermatitis/Eczema

Yes No

Latex Allergies

Yes No

Diabetes

Yes No

Glycolic Acids

Yes No

Hemophilia

Yes No

Alpha Hydrozy

Yes No

Pacemaker

Yes No

Heart Condition

Yes No

Blood Thinners

Yes No

High Blood Pressure

Yes No

Is your skin

Dry Oily Combination

Do you have problems with healing or scarring?

Are you light sensitive?

Have you experienced any recent changes in hair color or thickness?

Female Specific Information

Pregnant

Yes No

Menopause

Yes No Post

Regular Periods

Yes No

Breast Feeding

Yes No

Endocrine Problems

Yes No

Tanning or Sun Exposure

Sunbathing

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

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? *

By signing below you consent to the following statements.

I acknowledge that my skin might experience temporary irritation, breakout, tightness or redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity.

I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions.

I acknowledge that if I fail to use a minimal sunscreen (SPF30), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10am-2pm.

I acknowledge that this treatment is strictly elective cosmetic procedure and no medical claims have been expressed or implied.

I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are no part of the recommended take-home regimen for 2-4 weeks following treatment. Unless discussed with your aesthetician at Allana Davis Studio.

I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments

I release Allana Davis Studio and its staff of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.

Signature

Clear

SKIN TREATMENT EVALUATION

Medical Information:

In the past five years have you had or used?

Female Specific Information