Beauty by Charleen Medical History Form

Client Skin Health Questionnaire

Personal details
Full Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Email
example@example.com
Date of Birth

DayMonthYear
Date
Medical Details
Family Physician
Do You Smoke

YesNo
How Often
Please list any allergies? E.g. Aspirin, allergies to ingredients in products?
Please List all medications that you are currently taking
Are you currently taking any medication containing vitamin A?

YesNo
Are you pregnant?

YesNo
Trying to get pregnant?

YesNo
Hormone Therapy?

YesNo
Are you prone to cold sores?

YesNo
Skin Details
What is your skin type?

Dry (eg. Tight, Dull, & Flakey)Oily (Eg. Breakouts, Blackhads, & Shiny)Combination (Eg. Dry Cheeks, Oily T-Zone)Normal (Eg. Balanced & Smooth)
How sensitive is your skin?

MildModerateVery SensitiveNot Sensitive
Do you get any of the following?

Comedones/BlackheadsPustules/WhiteheadsCystic AcneOccasional SpotsHormonal BreakoutsNever Breakout
Are you prone to or do you currently have any of the following?

EczemaPsoriasisRosaceaHerpes SimplexNone of the above
Please tick Current Level of Stress

12345678910
Please tick your normal Level of Stress

12345678910
How many ounces of water do you drink daily?
List any vitamins / supplements that you take regularly
Do you Exercise?

YesNo
How Often?
Your Last Sunburn?
Do you use Tanning Beds?

YesNo
When you go out in the Sun, do you (Check One)

Always BurnUsually BurnSometimes BurnRarely BurnVery Rarely BurnNever Burn
Have you ever been under the treatment plan of a:

DermatologistPlastic SurgeonAesthetician
What Procedure?
Are you concerned about Skin conditions on your body (Tick all that apply)?

Sun SpotsSkin LaxityDry/Rough
What is your current skin care routine? Please complete each of the following
Do you use a daily environmental protection product (Sunblock)?

YesNo
Why not?
Please tick how you feel about the overall quality of your Skin

12345678910

What do you want your new skincare routine to focus most on (1-5)? 1 being area/condition that the bothers you most and 5 being an area that is not much of a concern for you

	1	2	3	4	5
Reduction in Fine Lines
Reduction in brown spots/sun damages
Reduction of Oil/acne
Acne Scars Diminished
Reduction of Redness
Reduction of Enlarged Pores
Reduction of Pigmentation
Improvement of Rosacea
Even Skin Tone

What are your Skincare Goals/ what would you like to achieve?
What Skincare Products are you interested in?

EnvironJane IredaleWaxpertsAdvanced Nutrition Programme
Images of Skin
Front

Browse Files

Cancelof
Right Side

Browse Files

Cancelof
Left Side

Browse Files

Cancelof
Declaration: This form including any additional data described above is an accurate reflection of my current health and discloses all relevant medical conditions.
Name

First NameLast Name
Signature

Clear
Date

DayMonthYear
Date
How would you prefer us to contact you?

Zoom CallPhone CallEmail
I agree with the storage and handling of this data for its intended purpose*

Yes
Should be Empty:

Client Skin Health Questionnaire

Medical Details

Skin Details