Language
English (US)
Client Intake Form
Facial Service
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Date of Birth
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
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4
5
6
7
8
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10
11
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18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
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1952
1951
1950
1949
1948
1947
1946
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1944
1943
1942
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1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Referred by:
*
Please Select
Google
Social Media
Client referral
Other
Your Health
Please answer all questions truthfully and to the best of your knowledge
Within the last year, have you been under a dermatologist’s or other physician’s care?
*
Yes
No
If yes, please specify:
Have you had any health problems in the past or present?
*
Yes
No
If yes, please specify:
Do you have any allergies?
*
Yes
No
If yes, please specify:
List any medications, supplements, vitamins, diuretics, slimming pills, Accutane, etc that you take regularly?
*
Do you smoke?
*
Yes
No
Do you exercise regularly?
*
Yes
No
Do you have any history of seizures or epilepsy?
*
Yes
No
Do you have metal implants or a pacemaker?
*
Yes
No
Do you wear contact lenses?
*
Yes
No
Do you sunbathe or use tanning beds?
*
Yes
No
Do you drink more than 4 caffeinated beverages daily (coffee, tea, soft drinks)?
*
Yes
No
Have you ever experienced claustrophobia?
*
Yes
No
Rate your stress level on a scale of 1 to 10
*
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
Your Skin
What are your specific concerns / challenges with your skin?
*
How do you feel about the quality of your skin?
*
Bad
1
2
3
4
5
6
7
8
9
Fantastic
10
1 is Bad, 10 is Fantastic
What skincare line(s) are you currently using?
*
What skin care products are you currently using on your face? Please check all that apply.
*
Soap
Cleanser
Toner
Moisturizer
Masque
Exfoliator
Eye Products
None
Other
Have you ever had facial treatments, chemical peels, microdermabrasions, or any resurfacing treatments?
*
Yes
No
If yes, when?
Do you use Retin-A, Renova, Adapalene or any other prescription skin products?
*
Yes
No
If yes, in the last month?
Are you currently using any products that contain the following ingredients?
*
Glycolic acid
Lactic acid
Exfoliating scrubs
Hydroxy acid products
Vitamin A derivatives (ie., Retinol)
None
Have you ever experienced the following conditions on your skin?
*
Flakiness
Tightness
Obvious dryness
None
Do you use an SPF daily?
*
If not, why?
Do you burn easily in moderate sunlight?
*
Yes
No
Do you suffer from sinus problems?
*
Yes
No
Do you ever experience burning, itching or stinging sensations on your skin?
*
Yes
No
Do you have a tendency to redness?
*
Yes
No
Are you taking any form of birth control?
*
Yes
No
N/A
Are you pregnant?
*
Yes
No
N/A
Trying to get pregnant?
*
Yes
No
N/A
Are you currently on any hormone therapy?
*
Yes
No
Is there anything else you would like me to know for your appointment?
*Confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment.
*
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