Skin Health Questionnaire
*Required to be submitted before your first appointment.
Full Name
*
First Name
Last Name
Phone Number
*
DOB
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What are your skin concerns? Select all that apply
*
Dark Spots
Wrinkles
Redness
Acne
Pore size
Blackheads
Compromised skin barrier
Maintenance
None, just seeking relaxation
Is your skin...
*
Oily/Acne-prone
Dry/Acne-prone
Oily
Dry
Combination
Sensitive
Normal
Please list your full skincare routine:
*
Do you have any allergies?
*
List any prescribed skin medication or topical cream you are currently using (ex. Retinol/Retin-A, Accutane)
*
Are you currently taking any supplements/medication? if yes please provide with the name of the brand (ex: hair, skin, & nails supplement, protein powder, greens, pre workout, birth control etc)
*
Do you get atleast 7-8 hrs of sleep daily?
*
Yes
No
If you’re struggling with acne, does anyone from your family (a parent or sibling) also have acne?
*
Yes it’s genetic
No
I don’t have acne
Are any of the foods listed below currently in your diet? (Check all that apply)
*
Dairy (milk, cheese, whey protein shake)
Peanuts, peanut butter
Cakes, pies, cookies, doughnuts
Sugar (energy drinks, soft drinks, pre packaged food)
Coffee
N/A
Do you have reason to believe you may have a hormone imbalance or gut issues? (If yes please explain why)
Dealing with stress?
Yes
No
Do you smoke?
*
Yes
No
Pregnant?
*
Yes
No
Do you exercise regularly?
*
Yes
No
Do you wear makeup regularly?
*
Yes
No
Do you wear sunscreen daily?
*
Yes
No
Are you interested in purchasing skincare & willing to commit to a skincare regimen?
*
Yes
Not at the moment
How would you prefer your skincare regimen to be?
*
Easy & short, 1-3 steps
Medium length, 3-5 steps
Elaborate, 5+ steps
During your facial would you prefer:
*
Scalp massage
Shoulder/Neck massage
Would you like your facial to be educational (where I explain what I’m doing during your facial) or do you prefer no talking?
*
Educational
Seeking relaxation no talking please!
Have you ever been treated for any skin condition by a dermatologist or esthetician?
*
Any other information you would like me to know?
Where did you hear/find me? If you found me on Instagram, drop your ig handle!
*
Do you consent to photos or videos of your facial treatment being taken & shared on social media platform? (To track progress and/or marketing purposes)
*
Please Select
Yes
No
Signature
Submit
Should be Empty: