Esthetics with Vanessa LLC Client Consultation Form

Esthetics with Vanessa LLC Client Consultation Form
NAME
DATE of BIRTH

MonthDayYear
Date
Address

ADDRESS

Street Address Line 2

CITYState / Province

ZIP
ZIP
PHONE
Format: (000) 000-0000.
FemaleMale
EMAIL
example@example.com
How were you referred to us?
Does your job require that you work outdoors?  No  YesOccupation
Occupation
2 Have you ever had a body spa treatment before?  No  YesWhat would you like to achieve from your treatment today?
What would you like to achieve from your treatment today?
1 Have you ever had a facial treatment before?  No  Yes, when?YOUR SKIN CARE
1 Have you ever had a facial treatment before?  No  Yes, when?
If yes, please specify when and what treatment
3 Which of the following best describes your skin type? Please check oneType I
Type IIIType IVType V
Type VI
Light skin tones—Burns easily, tans slightly
6 Do you use Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/vitamin A derivative products?  No  YesLight brown skin tones—Burns slightly, tans easily
8 Have you experienced Botox, Restylane, or collagen injections?  No  YesWhich medication?
In the last month?  No  YesIf yes, please specify:
5 Have you ever had chemicals peels, laser treatments, or microdermabrasion?  No  YesDark brown skin tones—Rarely burns, tans easily
4 Do you have any special skin problems or concerns pertaining to your face or body?  No  YesDark brown to black skin tones—Never burns, tans easily
If yes, please specify
7 Have you used acne medication?  No  Yes, when?If yes, please specify what and when last used:
If yes, please specify what and when last used
Which medication?
Which medication?
If yes, please specify
Cleanser
Toner
Day Moisturizer
Night Moisturizer
Exfoliator
Mask
Eye Product
Body LotionsSoapScrubsEye ProductOtherShower GelsMakeup Products10 Have you used any hair removal methods in the past six weeks?  No  Yes Check all that apply Shaving  Waxing  Electrolysis  Plucking  Tweezing Stringing  Depilatories  Other
SPF/Sunscreen
Scrubs
Makeup Products
Soap
Shower Gels
Body Lotions
Other
ExfoliatorBlackheads/whiteheads Wrinkles/fine lines Broken capillariesSPF/SunscreenDay MoisturizerMaskCleanserNight MoisturizerToner9 What skin care products are you currently using? List brands if knownClient Consultation Form—Continued11 What areas of concern do you have regarding your: Skin Check all that apply Breakouts/acneUneven skin tone Sun damageExcessive oil/shine RosaceaDull/dry skin Flaky skinRedness/ruddinessDehydrated Sun/liver/brown spotsOther11 What areas of concern do you have regarding your: Skin Check all that apply Breakouts/acneUneven skin tone Sun damageExcessive oil/shine RosaceaDull/dry skin Flaky skinRedness/ruddinessDehydrated Sun/liver/brown spotsOther11 What areas of concern do you have regarding your: Skin Check all that apply Breakouts/acneUneven skin tone Sun damageExcessive oil/shine RosaceaDull/dry skin Flaky skinRedness/ruddinessDehydrated Sun/liver/brown spotsOtherEyes (Check all that apply) Dehydrated Dark circlesPuffiness11 What areas of concern do you have regarding your: Skin Check all that apply Breakouts/acneUneven skin tone Sun damageExcessive oil/shine RosaceaDull/dry skin Flaky skinRedness/ruddinessDehydrated Sun/liver/brown spotsOther
Puffiness
Wrinkles OtherCracked/chapped lipsOther
12 Have you ever had an allergic reaction to any of the following Check all that apply12 Have you ever had an allergic reaction to any of the following Check all that applyLips (Check all the apply) Dehydrated12 Have you ever had an allergic reaction to any of the following Check all that applyAHAs Food Latex IodineMedication Shellfish Sunscreens PollenIf yes, please specify: Cosmetics Fragrance Animals Drugs OtherIf yes, please specify: Cosmetics Fragrance Animals Drugs OtherAHAs Food Latex IodineAHAs Food Latex IodineMedication Shellfish Sunscreens PollenMedication Shellfish Sunscreens PollenIf yes, please specify: Cosmetics Fragrance Animals Drugs OtherAHAs Food Latex IodineMedication Shellfish Sunscreens PollenIf yes, please specify: Cosmetics Fragrance Animals Drugs Other
14 Have you recently used any self-tanning lotions, creams or treatments?  No  YesHow often/when?
13 What SPF do you use on your face?
How often/when?How often/when?
How often/when?
15 Have you had any recent tanning bed or sun exposure that changed the color of your skin?  No  Yes13 What SPF do you use on your face?
If yes, please specify
If yes, please specify
<1 glass  1-3 glasses  4-7 glasses  8+ glasses16 How many glasses of water do you drink per day? Please check oneLIFESTYLEClient Consultation—Continued17 How many caffeinated beverages coffee, tea, soda, etc do you consume per day? Please check one None  1-2 drinks  3-5 drinks  6+ drinks17 How many caffeinated beverages coffee, tea, soda, etc do you consume per day? Please check one None  1-2 drinks  3-5 drinks  6+ drinks17 How many caffeinated beverages coffee, tea, soda, etc do you consume per day? Please check one None  1-2 drinks  3-5 drinks  6+ drinks17 How many caffeinated beverages coffee, tea, soda, etc do you consume per day? Please check one None  1-2 drinks  3-5 drinks  6+ drinks18 How many alcoholic beverages do you consume per week? Please check one I don’t drink  1-3 drinks  4-7 drinks  8+ drinks18 How many alcoholic beverages do you consume per week? Please check one I don’t drink  1-3 drinks  4-7 drinks  8+ drinks18 How many alcoholic beverages do you consume per week? Please check one I don’t drink  1-3 drinks  4-7 drinks  8+ drinks18 How many alcoholic beverages do you consume per week? Please check one I don’t drink  1-3 drinks  4-7 drinks  8+ drinks19 How many hours of sleep do you get per night? Please check one <3 hours  3-5 hours  6-8 hours  8-10 hours  10+ hours19 How many hours of sleep do you get per night? Please check one <3 hours  3-5 hours  6-8 hours  8-10 hours  10+ hours19 How many hours of sleep do you get per night? Please check one <3 hours  3-5 hours  6-8 hours  8-10 hours  10+ hours19 How many hours of sleep do you get per night? Please check one <3 hours  3-5 hours  6-8 hours  8-10 hours  10+ hours19 How many hours of sleep do you get per night? Please check one <3 hours  3-5 hours  6-8 hours  8-10 hours  10+ hoursFruits  Vegetables  Dairy/Eggs  Cheese  Poultry FishGrains/Bread  Processed Sugar  Processed Meats20 Which foods do you consume on a regular basis?Fruits  Vegetables  Dairy/Eggs  Cheese  Poultry FishGrains/Bread  Processed Sugar  Processed MeatsFruits  Vegetables  Dairy/Eggs  Cheese  Poultry FishGrains/Bread  Processed Sugar  Processed MeatsFruits  Vegetables  Dairy/Eggs  Cheese  Poultry FishGrains/Bread  Processed Sugar  Processed MeatsFruits  Vegetables  Dairy/Eggs  Cheese  Poultry FishGrains/Bread  Processed Sugar  Processed MeatsFruits  Vegetables  Dairy/Eggs  Cheese  Poultry FishGrains/Bread  Processed Sugar  Processed MeatsFruits  Vegetables  Dairy/Eggs  Cheese  Poultry FishGrains/Bread  Processed Sugar  Processed MeatsFruits  Vegetables  Dairy/Eggs  Cheese  Poultry FishGrains/Bread  Processed Sugar  Processed Meats21 What does your daily commute look like? Car  Bike  Public Transport  Walk  I don’t commute21 What does your daily commute look like? Car  Bike  Public Transport  Walk  I don’t commute21 What does your daily commute look like? Car  Bike  Public Transport  Walk  I don’t commute21 What does your daily commute look like? Car  Bike  Public Transport  Walk  I don’t commute21 What does your daily commute look like? Car  Bike  Public Transport  Walk  I don’t commute
22 How often do you travel on a plane? Never  1-2 times per year  1-2 times per quarter  Every month  Every week22 How often do you travel on a plane? Never  1-2 times per year  1-2 times per quarter  Every month  Every week22 How often do you travel on a plane? Never  1-2 times per year  1-2 times per quarter  Every month  Every week22 How often do you travel on a plane? Never  1-2 times per year  1-2 times per quarter  Every month  Every week22 How often do you travel on a plane? Never  1-2 times per year  1-2 times per quarter  Every month  Every week22 How often do you travel on a plane? Never  1-2 times per year  1-2 times per quarter  Every month  Every week22 How often do you travel on a plane? Never  1-2 times per year  1-2 times per quarter  Every month  Every week22 How often do you travel on a plane? Never  1-2 times per year  1-2 times per quarter  Every month  Every week22 How often do you travel on a plane? Never  1-2 times per year  1-2 times per quarter  Every month  Every week22 How often do you travel on a plane? Never  1-2 times per year  1-2 times per quarter  Every month  Every week
25 Do you smoke cigarettes, vape, or consume other tobacco products?  No  Yes23 How many hours do you spend in front of a screen or digital device?
30 Are you experiencing any menopausal symptoms?  No  YesIf yes, please specify
31 Are you undergoing any hormone replacement therapy treatments?  No  YesIf yes, please specify:
24 Do you exercise on a regular basis?  No  Yes<3 hours  4-6 hours  7-9 hours  10-12 hours  12+ hours
26 What are your stress levels on a scale from 1 to 5 1 = low stress, 5 = high stress?
27 Are you taking oral contraceptives?  No  YesFEMALE CLIENTS
28 Any recent changes to or from your contraceptive treatments?  No  Yes26 What are your stress levels on a scale from 1 to 5 1 = low stress, 5 = high stress?
If yes, please specify
29 Are you pregnant or trying to become pregnant?  No  YesIf yes, please specify what and when:
If yes, please specify what and when
If yes, please specify
If yes, please specify
32 Do you experience irritation from shaving?  No  YesMALE CLIENTS
33 Do you experience ingrown hairs as a result of hair removal?  No  YesIf yes, please specify:
If yes, please specify
May I call you at the provided phone number to confirm future appointments?  No  YesFUTURE APPOINTMENTS/CONTACT
May I contact you via mail/email about future promotions and news?  No  YesClient Consultation—Continued
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 (Printed)
Client Name (Signature)
Date

MonthDayYear
Date
Should be Empty: