Confidential Skin Health Questionnaire

Confidential Skin Health Questionnaire
General Information
Name*

First NameLast Name
Today's Date*

MonthDayYear
Age*
Date of Birth*

MonthDayYear
Date
Cell Phone*
Please enter a valid phone number.
Email*
example@example.com
Referral (website, social, friend, etc)*
**Make sure to list first and last name of the friend who referred you so that you both get your reward!**
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contact*

First NameLast Name
Phone Number*
Please enter a valid phone number.
What is the reason for your visit today?
Expectations & History
Which conditions would you like to improve?*

Acne ScarringAcneAge SpotsEnlarged PoresFine Lines/WrinklesBroken CapillariesStretch MarksSurgical/Facial ScarsOther
Have you ever had facial treatment in the past?*

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

NormalOilySensitiveDryCombinationSun Damaged
Do you ever experience*

Flakiness?Redness?Tightness?Excessive oily shine during day?None of the above
What is your present skin regimen?*

Soap & Water OnlyCleanserTonerMasqueMoisturizerExfoliationSunscreen Every DayOther
Are you ever exposed to chemicals, oils, or other caustic substances that may aggravate your skin?*

YesNoIf yes, what are they?
Do you blush easily?*

YesNo
If yes, what are the contributing factors?

EmotionsTemperature ChangesFoodsOther
Do you

Sun bathe?Use a tanning bed?How Often?
Have you ever had

chemical peels?microdermabrasion?facial surgery?cosmetic surgery?Botox?collagen injections?laser resurfacing?How recently?
Are you under treatment for any current skin condition?*

YesNoIf yes, what?
Does your skin heal*

fast?scar?pigment?
Do you bruise easily?*

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

YesNo
What medications/hormone replacement/vitamins do you presently take?
Do you currently use

Accutane®Retin-A®Renova®Topical AntibioticsDifferinTazaracHydroquinoneAlpha Hydroxy AcidsIf yes, when and for how long?
Any personal or family history of skin cancer?*

YesNoIf yes, please provide detail
How would you describe your overall health?*

ExcellentGoodFairPoor
Have you had any of the following, past or present? (Please provide details in box below if any of the following ask)

Acne (please list when)Allergies (please list)Arthritis/BursitisBlood Pressure (please list high or low)Breast ImplantCancerCataractsCholesterol (please list high or low)ClaustrophobiaDiabetesDiarrhea/ConstipationEczema (please list where)EpilepsyHay FeverHeadaches (please list how often)Heart Disease/Conditions (please provide detail)HepatitsHIV/AIDSInfectionsLupusMenopausalMetal ImplantsPace MakerPhlebitisSerious Injury (please list)Sleep ProblemsHyperthyroidismHypothyroidismVaricose VeinsDo you smoke?Do you wear contact lenses?
Please provide any details from the section above if you checked a box that requires elaboration:
Have you ever had a reaction to

Cosmetics?Metals?Medication?Food?Fragrance?Airborne particles?If yes, please explain
FOR WOMEN

Oral contraceptives?Pregnant or trying to get pregnant?Taking hormone replacements?Experience hormone imbalance?
FOR MEN

Shave with electric razor?Shave with razor?Experience breakouts when shaving?Experience ingrown hair?
Lifestyle & Diet
Rate your stress level:*

LowMediumHigh
How many ounces of water do you consume daily?*
How many cups of caffeine-type beverage (coffee, tea, soft drinks) do you consume daily?*

01-34 or more
I 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 by a dermatologist. 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 Ashley Eaton and AE Aesthetics, harmless from any liability for adverse reactions that may result from this treatment. I have read and understood all of the foregoing information. *

Clear
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Confidential Skin Health Questionnaire

General Information

Expectations & History

Lifestyle & Diet