Skincare Assessment

1
What areas of concern do you have regarding your skin:* This field is required.
Breakouts/acne
Uneven skin tone
Blackheads/whiteheads
Sun damage
Excessive oil/shine
Wrinkles/fine lines
Rosacea
Dull/dry skin
Broken capillaries
Flaky skin
Redness/ruddiness
Dehydrated
Sun spot/liver spot/brown spot
Other
2
Specify
3
What is your name?* This field is required.
First Name
Last Name
4
What is your Phone Number?* This field is required.
Area Code
Phone Number
5
Have you ever received a skincare treatment?* This field is required.
YESNO
6
What type of service was performed?
7
What areas of concern do you have regarding your eyes?* This field is required.
Dehydrated
Wrinkles
Puffiness
Dark circles
Other
None
8
Specify
9
What areas of concern do you have regarding your lips?* This field is required.
Dehydrated
Cracked/Chapped lips
Other
None
10
Specify
11
Do you have any other special skin problems or concerns pertaining to your face or body?
Huge
Large
Normal
Small
Ok
Ok
12
Have you ever had chemical peels, laser or microdermabrasion?* This field is required.
YESNO
13
Which service & when was it performed?
14
Do you currently use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products? * This field is required.
YESNO
15
Which products and how is it used?
16
Describe your daytime and nighttime skin care routine* This field is required.
Huge
Large
Normal
Small
Ok
Ok
17
Have you recently used any self-tanning lotions, creams or treatments? * This field is required.
YESNO
18
Have you used any of the following facial hair removal methods in the past 6 weeks?* This field is required.
Waxing
Shaving
Electrolysis
Plucking
Tweezing
Threading
Depilatories
None
19
Have you ever had an allergic reaction to any of the following?* This field is required.
Cosmetics
Medicine
Food
Animals
Sunscreens
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex
Drugs
Other
None
20
Specify
21
How does your skin react to UV light exposure?* This field is required.
Always burns easily, never tans
Always burns, tans slightly
Burns moderately, tans gradually
Seldom burns, tans well
Rarely burns, almost always tans well
Never burns, deep tan
22
What SPF do you use on your face? How often/when? * This field is required.
23
What SPF do you use on your body? How often/when? * This field is required.
24
Have you had any recent tanning bed or sun exposure that changed your skin tone? * This field is required.
25
Have you received Botox, Restylane or Collagen injection treatments?* This field is required.
26
Do you have any skin concerns related to contraceptives?* This field is required.
YESNO
27
Are you pregnant or trying to become pregnant?* This field is required.
YESNO
28
Are you lactating?* This field is required.
YESNO
29
Do you have any skin concerns related to menopause?* This field is required.
YESNO
30
Are you undergoing any hormone replacement therapy?* This field is required.
YESNO
31
Please use this space to complete answers where space was insufficient. (Please include the number of the question)
Huge
Large
Normal
Small
Ok
Ok
32
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.
YESNO
33
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.* This field is required.
Yes
34
Signature* This field is required.
Clear
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