Beauty by Charleen Medical History Form

Client Skin Health Questionnaire

Personal details
Full Name *

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Email
example@example.com
Date of Birth

Day Month Year
Date
Medical Details
Family Physician
Do You Smoke

Yes No
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?

Yes No
Are you pregnant?

Yes No
Trying to get pregnant?

Yes No
Hormone Therapy?

Yes No
Are you prone to cold sores?

Yes No
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?

Mild Moderate Very Sensitive Not Sensitive
Do you get any of the following?

Comedones/Blackheads Pustules/Whiteheads Cystic Acne Occasional Spots Hormonal Breakouts Never Breakout
Are you prone to or do you currently have any of the following?

Eczema Psoriasis Rosacea Herpes Simplex None of the above
Please tick Current Level of Stress

1 2 3 4 5 6 7 8 9 10
Please tick your normal Level of Stress

1 2 3 4 5 6 7 8 9 10
How many ounces of water do you drink daily?
List any vitamins / supplements that you take regularly
Do you Exercise?

Yes No
How Often?
Your Last Sunburn?
Do you use Tanning Beds?

Yes No
When you go out in the Sun, do you (Check One)

Always Burn Usually Burn Sometimes Burn Rarely Burn Very Rarely Burn Never Burn
Have you ever been under the treatment plan of a:

Dermatologist Plastic Surgeon Aesthetician
What Procedure?
Are you concerned about Skin conditions on your body (Tick all that apply)?

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

Yes No
Why not?
Please tick how you feel about the overall quality of your Skin

1 2 3 4 5 6 7 8 9 10

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?

Environ Jane Iredale Waxperts Advanced Nutrition Programme
Images of Skin
Front

Browse Files

Cancel of
Right Side

Browse Files

Cancel of
Left Side

Browse Files

Cancel of
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 Name Last Name
Signature

Clear
Date

Day Month Year
Date
How would you prefer us to contact you?

Zoom Call Phone Call Email
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