CONFIDENTIAL SKIN HEALTH QUESTIONNAIRE

CONFIDENTIAL SKIN HEALTH QUESTIONNAIRE
PLEASE PRINT
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Street
Apt. #
City
State
Zip
Phone Home
Work
Mobile
Dermatologist/physician
Phone
Emergency Contact
Your occupation
E Mail
example@example.com
Referred by

FriendMailerWalk-byE-mailGift CertificateOther
Skin Care Professional Name:
1. What is the reason for your visit today?*
2. What special areas of concern do you have?*
2. If you could change 3 things about your skin, what would they be?*
EXPECTATIONS and HISTORY
3. Which conditions would you like to improve?*

Acne scarringHyperpigmentationAcneBroken capillariesAge spotsStretch MarksEnlarged PoresSurgical/facial scarsFine lines & wrinklesOther
4. Have you ever had a facial treatment in the past?*

YesNo
5. What was your experience?*
6. How would you describe your skin?*

NormalDryOilyCombinationSensitiveSun Damaged
7. How would you rate your skin? (Circle one)*

I Always burns, never tansII Always burns easily, tans slightlyIII Burns moderately, tans graduallyIV Seldom burns, Always tans wellV Rarely burns, deep tanNever burns, deeply pigmented
8. Do you ever experience*

FlakinessTightnessRednessExcessive shine during the dayNone of the above
9. What is your present skin regimen?*

Soap & water onlyCleanserTonerMoisturizerMasqueExfoliationSun block every dayNo current regimenOther
What product/brands?*
10. Are you ever exposed to chemicals, oils, or other caustic substances that may aggravate your skin?*

YesNo
If yes, what are they?
11. Do you blush easily?*

YesNo
If yes, what are the contributing factors?

EmotionsFoodsTemperature changesOther
12. Do you*

Sun batheUse a tanning bedI don't sun bathe or use a tanning bed
How often?
13. Have you ever had*

PeelsMicrodermabrasionFacial SurgeryCosmetic SurgeryBotoxCollagen injectionsLaser ResurfacingNone of the above
If yes, how recently?
14. Are you under treatment for any current skin conditions?*

YesNo
If yes, what?
14. Have you ever been diagnosed with any skin conditions?*

YesNo
If yes, what?
15. How does your skin heal?*

FastScarsPigments
16. Do you bruise easily?*

YesNo
17. Do you get sores/blisters (Herpes Zoster/Shingles)?*

YesNo
18. What medications/hormone replacement/vitamins do you presently take?*
19. Have you ever used:*

AccutaneRetin-ARenovaTopical AntibioticsDifferinTazaracHydroquinoneAlpha Hydroxy AcidsNone of the above
If yes, when and for how long?
20. Any personal or family history of skin cancer?*

YesNo
Provide detail:
21. How would you describe your overall health?*

ExcellentGoodFairPoor
22. Have you had any of the following, past or present?*

AcneAllergiesArthritis or BursitisBlood PressureBreast ImplantCancerCataractsCholesterolClostrophobicDiabetesEczemaEpilepsyHay feverHeadachesHeart Disease/ConditionsHepititisHIV/AidsInfectionsLupusMenopausalMetal ImplantsPace MakerPhlebitisSerious InjurySleep ProblemsThyroidVaricose VeinsNone of the above
Do you smoke?*

YesNo
Do you wear contact lenses?*

YesNo
23. Have you ever had a reaction to:*

CosmeticsMetalsMedicationFoodFragranceAirborne particlesNo reactions to anythingOther
24. For WOMEN: Do you use oral contraceptives?*

YesNo
Are you pregnant or trying to become pregnant?*

YesNo
Are you taking hormone replacement?*

YesNo
Do you experience hormone imbalances?*

YesNo
25. For MEN: Do you shave with:*

Electric shaverRazorNot applicable
Do you experience skin breakouts?*

YesNo
Do you have ingrown hair?*

YesNo
LIFESTYLE & DIET
1. Is your stress level:*

HighMediumLow
2. Do you normally sleep well?*

YesNo
3. Do you exercise regularly?*

YesNo
4. Do you have food intolerances?*

YesNo
If so, what?
5. Do you follow any special diet?*

YesNo
If yes, what kind?
6. How many glasses of water do you consume daily (glasses)?*
7. How many cups of caffeine-type beverage (coffee, tea, soft drinks) do you consume daily?*

1-3 cups4 or more
8. 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?*

YesNo
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
I,___________________________, do 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 appointment 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 release and hold harmless the skin care professional Valerie Dennis, Dermalessence, and the staff harmless from any liability for adverse reactions that may result from this treatment.
Signature

Clear
Date

MonthDayYear
Date
POLICIES
Signature

Clear
Date

MonthDayYear
Reservation and Cancellation Policy applies to ALL appointments. A valid Credit card is required at time of booking to secure the booking time. We understand that unanticipated events happen. In our desire to be effective and fair to all clients, the following policies are honored:

Cancellation Policy:
24 hour advanced notice is required when cancelling an appointment. This allows the opportunity for someone else to schedule an appointment. If you are unable to give us 24 hour notice and we are unable to fill your time slot, you will be charged $25.00 to the credit card on file. If the payment is declined for any reason, you will be invoiced through square for the missed appointment and invoice must be paid before any appointments will be scheduled in the future.

No-Shows:
Anyone who either forgets or consciously chooses to forgo their appointment for whatever reason will be considered a "no-show" and will be charged 100% of the value of their "missed" appointment. If the card on file is declined, you will be invoiced through Square for the missed appointment and invoice must be paid before any other appointments will be scheduled for the future.

Late Arrivals:
If you arrive late, your session may be shortened in order to accommodate others whose appointments follow yours. Depending upon how late you arrive, your therapist will then determine if there is enough time remaining to start a treatment. Regardless of the length of the treatment actually given, you will be responsible for the "full" session. Out of respect and consideration to your therapist and other customers, please plan accordingly and arrive on time.

Minors/Children:
Due to the safety and liability regulations, children are not permitted in the treatment room unless they are the one receiving the service. If under the age of 18, a parental consent form must be filled out by a parent/guardian at time of service. Parent/Guardian MUST remain on site during the minor service.

If you are not satisfied with your service or products, please contact your skin care professional within 24-hours after your appointment so that the situation may be corrected.
Should be Empty:

CONFIDENTIAL SKIN HEALTH QUESTIONNAIRE

PLEASE PRINT

EXPECTATIONS and HISTORY

LIFESTYLE & DIET

INFORMED CONSENT RELEASE

POLICIES