Facial Consultation Form

NAME
Facial Consultation Form

Answer the best you can! It's just to give me an idea to help you achieve your skincare goals; please take your time.
DATE of BIRTH

MonthDayYear
Date
SEX

FemaleMaleOther
YOUR SKIN CARE

Answer the best you can
Have you ever had a facial treatment before? YES/NO If yes, please specify when and what treatment:
Have you ever had chemicals peels, laser treatments, or microdermabrasion? YES/NO if yes, in the last month?
What is your occupation? Does your work require you to work outdoors? YES/NO
What would you like to achieve from your treatment today?
Which of the following best describes your skin type? Please check one

Type I Fair skin tones—Always burns, never tansType 2 Light skin tones—Burns easily, tans slightlyType 3 Fair to olive skin tones—Burns moderately, tans moderatelyType 4 Light brown skin tones—Burns slightly, tans easilyType 5 Dark brown to black skin tones—Never burns, tans easily
Do you use Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/vitamin A derivative products? YES/NO if yes, please specify what and when last used:
Have you used acne medication? YES/NO If yes, please specify what medication and last used
Do you have any special skin problems or concerns pertaining to your face or body? if yes, please specify
What skincare products are you currently using on your face?

CleanserTonerDay MoisturizerNight MoisturizerExfoliatorMaskEye ProductSPF/ SunscreenScrubsMakeupSoap/ Shower gelsBody Lotions
Have you had/used any hair removal methods in the last 6 weeks? ex) shaving, tweezing, wax/sugar, electrolysis, depilatories, other:
What areas of concern do you have regarding your: Skin (check all that apply)

Breakouts/AcneSun DamageRosaceaFlaky SkinSun/liver/brown spotsUneven Skin ToneExcessive oil/shineDull/Dry SkinRedness/RuddinessBlackheads/whiteheadsWrinkles/fine linesBroken Capillaries/spider veinsDehydratedOtherlipseyes
Have you ever had an allergic reaction to any of the following (check all that apply)

cosmeticsfragancesanimalsdrugsAHAsfoodLatexIodinemedicationshellfishsunscreenspollen
What SPF do you use on your face? when/how often?
Have you recently used any self-tanning lotions, creams or treatments? if yes, please speficy:
Have you had any recent tanning bed or sun exposure that changed the color of your skin? YES/NO If yes, please specify:
HEALTH HISTORY

Answer the best you can
Are you taking any oral contraceptives? YES/NO if yes, please specify:
Have you experienced any recent changes to or from your contraceptives? YES/NO if yes, please specify:
Are you pregnant or trying to become pregnant? YES/NO
Are you experiencing any menopausal symptoms? YES/NO
Are you currently undergoing any hormone therapy treatments? YES/NO if yes please specify:
LIFESTYLE

Answer the best you can
How many glasses of water do you drink per day?
How many caffeinated beverages (coffee, tea, soda, etc.) do you consume per day?
How many alcoholic beverages do you consume per week?
How many hours of sleep do you get per night?
Which foods do you consume on a regular basis? FRUITS, FISH, VEGETABLES, GRAINS/BREAD, DAIRY/EGGS, PROCESSED SUGAR, CHEESE, PROCESSED MEATS, POULTRY..
In average, how many hours do you spend in front of a screen or digital device?
Do you exercise on a regular basis? YES/NO
Do you smoke cigarettes, vape, or consume other tobacco products? YES/NO
What are your stress levels on a scale from 1 to 5 (1 = low stress, 5 = high stress)?
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure,and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or the technician/esthetician/skin care professional from liability and assume full responsibility thereof.
Client Name (Signature)
Date

MonthDayYear
Date
Should be Empty:

Facial Consultation Form

YOUR SKIN CARE

HEALTH HISTORY

LIFESTYLE