About Face

Client's Name

First NameLast Name

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?

If yes, where, how frequently, and when?

Have you had previous laser use

If yes, where, and what was the result?

Do you smoke?

Other

Do you consume alcohol?

Other

Have you had any recent sun exposure?

Other

Have you recently used any self-tan products?

Have you recently tweezed, plucked, or waxed?

Do you have any tattoos or permanent make-up?

Please check all conditions you have been or are affected by

Do you have regular periods?

Are you going through menopause?

Are you trying to become pregnant?

Are you pregnant or lactating?

Do you experience breakouts during or around your menstrual cycle?

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

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

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

Have you used Glycolic/AHA?

Which ones? How does your skin react to them?

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

Have you done any exfoliation in the last two weeks?

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

Please list any types of facials and peels you’ve had in the past

Chemical Peel

Botox

Fillers

Facial Rejuvenation

Laser Resurfacing

Microdermabrasion

Facial Surgery

Skin Cancer or Precancerous Lesions

Do you wear contact lenses?

Do you have a history of acne or periodic breakouts?

If yes, please check all that apply

How often do you experience breakouts?

Please check the boxes of conditions your skin is prone to

Have you ever had a skin allergy or sensitivity?

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

How do you want to improve your skin?

What specific areas do you want to treat? Please check all that apply

What other concerns do you have?

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

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?

Do you have concerns with discomfort of pain?

Do you consider yourself open-minded?

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

Date

For Women Only

For All

Have you previously had

Wellness Questionnaire

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