New Client Intake Form

New Client Intake Form
Your Information
Name
DOB
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Cell Phone
Email
example@example.com
Medications
Please list any medications you are currently, or have taken:

AntiobioticsAccutaneBenzoyl PeroxideRetin ACream or GelTazoracDifferinAzelexAvitaCleocin-TE-Mycin-TCopaxoneCorticosteriodsQuinineAndrostendioneTestosteroneProgesteroneThyroidGonadotrophinDanzolCycolsporinLithiumIsoniazidImmuranDisulfuramDilantin/TegretolSteroidsMarijuanaCocaine/SpeedOther
If you selected any medications above, please let us know when AND how long you have been or did take them
Medical History (please check all that apply)

Herpes SimplexEczemaPsoriasisHepatitisCancerStaph Infection/MRSAHIV/AIDSThyroid ProblemsHormone ProblemsHysterectomyOvary(ies) RemovedPacemakerHemophiliaLupusAnemiaHigh Blood PressureDiabetesMetal Pins in Body
Your Primary Care Physician:
Name:
Phone:
Are you under a dermatologist’s or other physician’s care?

YesNo
If yes, doctor's name:
Lifestyle Considerations
Have you ever had any reaction to any products or anything you have put on your face?

YesNo
If yes, what products?
Please check if you are allergic to any of these

SulfurAspirinLatex
List any other allergies you know of:
Do you use fabric softener or fabric softener sheets in the dryer?

YesNoSometimes
Do you swim in a chlorinated pool?

YesNoSometimes
Do you work around chemicals, tars, oils, grease or inks?

YesNoSometimes
Occupation:
Do you work nights?

YesNoSometimes
Are you currently under a lot of stress? (Common stress is job loss, new job, wedding, romantic breakup, death in the family or close friends, graduation, difficult home life, long commute, heavily schedule)

YesNo
Women: Do you use birth control pills, shots or use an IUD?

YesNo
If yes, what form of birth control do you use?
If yes, what brand?
Are you pregnant or nursing?

YesNo
Men: Do you have shaving irritation?

YesNo
What type of razor do you use for shaving?
Diet
Do you consume the following?

Fast FoodProcessed FoodSalty SnacksMilk/YogurtCheeseWhey or Soy ProteinPeanut ButterPeanutsSushiKelp and SeaweedMiso SoupSoyVitaminsSeafood
If you selected any food above, please let us know what food and how often per week
Products Currently Using
Cleanser, Toner, Serums, Moisturizers, Sunscreen, Masks, Foundation, Blush, Exfoliant (Acids, Serums, Scrubs), Acne Medications, Anything Else?
Please Provide All Product Names
Other Treatments
What else have you done for your skin in the last 90 days?

Chemical PeelMicrodermabrasionDermabrasionLaser Hair RemovalLaser Rejuvenation/ResurfacingSkin Cancer RemovalFacial WaxingElectrolysisOther
If you selected any treatments above, please let us where and when you received treatment
How did you hear about us?
Signature
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New Client Intake Form

Your Information

Medications

Your Primary Care Physician:

Lifestyle Considerations

Diet

Products Currently Using

Other Treatments