Skin Harmony Consultation
Name
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First Name
Last Name
Today's Date
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Month
-
Day
Year
Date Picker Icon
Date of Birth
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Phone Number
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Area Code
Phone Number
E-mail
*
If you were referred, please mention by whom
Your Skin
What are your skin care goals?
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What are your skin care challenges?
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Wrinkles / Fine Lines
Hyperpigmentation / Sun Damage
Acne / Acne Scarring
Redness / Rosacea
Aging
Melasma
Sensitivity
Other
Have you ever had a facial or skin treatment before?
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Yes
No
If Yes, when and what type of treatment was it?
What Skin Care Products do you currently use?
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Cleanser / Face Wash
Bar Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturizer
Sunscreen
Eye Product(s)
Lip Product(s)
If you are seeking corrective treatments please detail the SPECIFIC products
(BRAND & PRODUCT TYPE/NAME)
you are currently using so I can best answer any questions on ingredients and help you meet your skin care goals.
Cleanser / Face Wash
Face Scrub / Exfoliants
Toner
Serums
Moisturizer(s)
Sunscreen
Eye Product(s)
Lip Product(s)
Do you/have you used Retin-A, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?
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Yes, currently using
Yes, but not within the last 30 days
Yes, but not within the last 6 months
No
Not sure
Please specify which product or type, if you answered 'Yes, currently using' to above.
Have you received any of these hair removal services in the last 30 days?
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Waxing
Sugaring
Threading
Electrolysis / Laser
Depliatory Cream
Shaving
None
If checked, please note last time.
Have you ever received chemical peels, laser services, or microdermabrasion treatments?
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Yes, within the last month
Yes, within the last 2-3 months
No
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?
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Yes
No
Have you done microneedling or plasma/fibroblast treatments in the last 2 months?
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Yes
No
Your Health
Have you experienced any of these health conditions in the past or present?
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Hormone Imbalance
Cancer / Systemic Disease
High Blood Pressure
Diabetes
Heart problem
Arthritis
Auto-Immune Disorders
Asthma
Epilepsy / Seizure Disorder
Fever Blisters
Herpes
Frequent Cold Sores
HIV/AIDS
Lupus
Depression/Anxiety
Hepatitis
Headaches / Migraines
Other
None
If you checked yes to any of these please provide further information. If not mark N/A
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Do you?
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Wear contact lenses
Have a pacemaker
Have metal implants
Have body piercings
No, not Applicable
Do you take any of the following dietary / health supplements?
Multivitamin
Vitamin C
Vitamin D/D3
Zinc
Omega 3 / Fish Oil
B Complex / B12
Garlic
Calcium
Folic Acid
Melatonin
Coenzyme Q10
Biotin
Other
If other, please list
Any known allergies?
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Aspirin
Tree Nuts
Latex
Dairy
Fruits
Vegetables
Shellfish
Iodine
Fragrances / Essential Oils
Other
None
If Other, please specify
Have you used or been prescribed any medications (topical or oral) for acne / acne control?
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Yes
No
If yes, please specify what and date last used
Are you a smoker?
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Yes
No
Social
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)
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Yes
No
Have you ever experienced claustrophobia?
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Yes
No
Please rate your stress level
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Low
Medium
High
Are you taking birth control?
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Yes
No
N/A
If yes, what kind
Are you pregnant or trying to become pregnant?
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Yes
No
Recently had a baby and am breastfeeding
N/A
Any menopause issues?
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Yes
No
N/A
If yes, please specify
Are you undergoing any hormone replacement therapy?
Yes
No
If yes, please specify
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 skin care professional from liability and assume full responsibility thereof.
Yes
Signature
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