About Face

About Face

Patient History
Client's Name

First NameLast Name
Date

MonthDayYear
Date
Requested Procedure and Location
List any allergies you have including medications
List all medications and vitamins you are currently taking
Have you recently used Accutane, Retin-A or any sort of bleaching agent?

YesNo
If yes, where, how frequently, and when?
Have you had previous laser use

YesNo
If yes, where, and what was the result?
Do you smoke?

QuitYesNoOther
Do you consume alcohol?

QuitYesNoOther
Have you had any recent sun exposure?

QuitYesNoOther
Have you recently used any self-tan products?

YesNo
Have you recently tweezed, plucked, or waxed?

YesNo
Do you have any tattoos or permanent make-up?

YesNo
Please check all conditions you have been or are affected by

AsthmaCardiac ProblemsDiabetesEczemaEpilepsyFever BlistersChronic HeadachesHepatitisHerpesHigh Blood PressureHIV +HysterectomyImmune DisordersImmunosuppressionKeloidsLupusMedical ImplantsMelanomaPacemakerPoor wound healingPsoriasisPsychological ProblemsRosaceaSclerodermaSeizures triggered by lightSensitivity to lightSinus ProblemsUrinary or kidney problemsVitiligoNone
For Women Only
Do you have regular periods?

YesNo
Are you going through menopause?

YesNo
Are you trying to become pregnant?

YesNo
Are you pregnant or lactating?

YesNo
Do you experience breakouts during or around your menstrual cycle?

YesNo
If yes, during pregnancy, did you ever experience hyperpigmentation or “pregnancy mask”?

YesNo
For All
Are you currently under the care of a physician for your skin?

YesNo
Have you ever seen a dermatologist or other physician for your skin?

YesNo
Have you used Glycolic/AHA?

YesNo
Which ones? How does your skin react to them?

YesNo
What skin care products do you frequently use? Please check all that apply

SoapCleanserTonerSerumScrubMaskMoisturizerSunscreenOther
Have you done any exfoliation in the last two weeks?

YesNo
Have you ever used any products that caused a bad reaction?

YesNo
Please list any types of facials and peels you’ve had in the past
Have you previously had
Chemical Peel

YesNo
Botox

YesNo
Fillers

YesNo
Facial Rejuvenation

YesNo
Laser Resurfacing

YesNo
Microdermabrasion

YesNo
Facial Surgery

YesNo
Skin Cancer or Precancerous Lesions

YesNo
Do you wear contact lenses?

YesNo
Do you have a history of acne or periodic breakouts?

YesNo
If yes, please check all that apply

PimplesCystsWhiteheadsAcne ScarsBlackheadsEnlarged Pores
How often do you experience breakouts?

FrequentlyOccasionallyRarely
Please check the boxes of conditions your skin is prone to

Fine LinesDull AppearanceDeep WrinklesSmall WrinklesUneven PigmentationSagging SkinBroken CapillariesPink or red patches with flaky skinDeep WrinklesSagging Skin
Have you ever had a skin allergy or sensitivity?

YesNo
If yes, what happened when this occurred? Check all that apply

RashHivesIrritationSwellingPeelingItchingOther
How do you want to improve your skin?
What specific areas do you want to treat? Please check all that apply

FaceNeckChestBackHandsOther
What other concerns do you have?

HyperhidrosisAcneLarge PoresCreepy SkinHyperpigmentationHands
When you look in the mirror, what do you see that needs improvement? What bothers you? Please mark on the face below with ‘x’s and number in order of concern
Wellness Questionnaire
Do you have any upcoming events in the next 6 months?
Do you have any general concerns about your face or body?
How many times per week do you exercise?
Where do you work?
Do you have children?

YesNo
Do you have concerns with discomfort of pain?
Do you consider yourself open-minded?

YesNo
What do you do for entertainment?
I, full name, do hereby agree to the following. I am allowing About Face to take photos of my treatment and/or treated areas to be used for the purpose of monitoring my progress.

In addition:

I give permission for my photos to be used in education initial (initial).
I give permission for my photos to be used in advertising   initial (initial).
I give permission for my photos to be used on the About Face website   initial (initial).
At my request, my identity will remain anonymous   initial (initial).
At my request, my photos will only be used for my chart   initial (initial).
Client Consent

I certify that the preceding medical, personal, and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor, or nurse of my current medical or health conditions to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.

I understand that the services offered by About Face are not a substitute for medical care, and that any information provided by the cosmetic therapist is for educational purposes only and not diagnostically prescriptive in nature. I understand that the information herein is to aid the staff at About Face in giving better service and is completely confidential
Signature

Clear
Date

MonthDayYear
Date
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Should be Empty:

For Women Only

For All

Have you previously had

Wellness Questionnaire

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