Facial Questionnaire:
Client Health History
Today's Date
-
Month
-
Day
Year
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
How should we contact you?
Phone
Email
Emergency Contact
*
First + Last Name
Relationship to You
Phone Number
How did you hear about us?
*
What are your skin concerns and challenges today?
What are you currently using on your skin?
Do you have any allergies?
Yes
No
If yes, please elaborate:
Have you been diagnosed with any skin cancers?
Yes
No
If yes, located where?
Are you wearing contacts today?
Yes
No
Are you currently pregnant?
Yes
No
Are you taking any medications that I need to be aware of?
Yes
No
If yes, please specify:
Have you had a chemical peel microdermabrasion treatment in the last six months?
Yes
No
Have you taken Accutane in the last 12 months?
Yes
No
Have you used Retin-A in the last 12 months?
Yes
No
Signature
Submit
Should be Empty: