Bella Donna Skin Studio Client Profile

Bella Donna Skin Studio

Client Profile
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Client's Name*

First NameLast Name
DOB*
Age*
Gender: Please enter F for female, M for male*
Address:*
City:*
State:*
Zip code:*
Phone: (cell)*
Phone: (work)
Email*
example@example.com
Preferred method of contact*
Primary Care Physician:*
Physician Phone:
Referred By:*
Emergency Contact Name and Phone:*
Nutritional Information
How many meals/snacks eaten daily:*
Time of main meal eaten daily:*
Type of food groups eaten:*
Fast food meals per week:*
Food intolerances?*

YesNo
If yes, please list any food intolerances:*
Food allergies? (Dairy, Gluten, Nuts, Mushrooms, Citrus, Grapes, Apples, etc.?*

YesNo
If yes, please list any food allergies:*
Daily water intake in fluid ounces:*
Daily Caffeinated beverage in oz.:*
Please check all that apply:*

Weight fluctuationsFat free dietDigestion issuesAnemiaDiabetesConstipation issuesN/A to all
Sun Exposure and Genetic History
Location of birth and first 25 years:*
Tanning bed history:*
Sunburn history (childhood & teenage years):*
Do you wear a broad spectrum (UVA & UVB) sunscreen daily?*

YesNo
Recently used any self-tanning lotions or spray tan treatments?*

YesNo
Fitzpatrick Scale (how your skin reacts to sun exposure) How do you tan?*

BurnUsually BurnSometimes burnRarely burnNevery Burn-BrownNever Burn-Black
What is your Ethnicity and Heritage?*
Natural Eye Color:*
Natural Hair Color:*
Skin tone: Please select one answer.*

Pale/WhiteLightMediumReddishFreckledSallowLight OliveMedium OliveDark OliveLight BrownMedium BrownDark BrownSoft BlackBlack
Please answer Yes or No if you have the MC1R Gene: (redhead) *
General Health and Medical History
Are you currently seeing a physician for any reason?*

YesNo
If yes, explain reason:*
Have you undergone any major surgery?*

YesNo
If yes, please specify:*
Are you or have you undergone chemotherapy or radiation for cancer treatment?*

YesNo
If yes, please explain:*
Do you have any health problems?*

YesNo
If yes, please list:*
Do you have any allergies or skin sensitivities?*

YesNo
If yes, please check all that apply:*

hydroxy acidslatexiodinepollenhydrocortisoneaspirinaloe veraN/A to all
If yes, please check applicable cont.:*

antibioticsfragrances/oilshydroquinonecosmeticssunscreenotherN/A to all of above
Have you had any recent dental x-rays?*

YesNo
Do you have any metal implants, a pacemaker, or body piercings?*

YesNo
Please check all that apply:*

hemophiliac/bleeding disorderimpaired lymphatic systemhepatitisbruise easilyvaricose veinsimmune disordersHIV/AIDSherpesepilepsydiabetesthyroid disordersvitiligolupusasthmaN/A to all of above
Please check all that apply cont.:*

eczemadermatitiscardiac valve diseasepsoriasisarthritisclaustrophobicepi pen carriedosteoporosissuperfluous hairhormonal imbalanceany active infectionkeloid scarringfatiguedepressionN/A to all of above
Do you currently take any oral medications? (include vitamins, prescriptions, oral hormones, birth control pills, antibiotics, pain, tranquilizers, allergy, diuretics, cardiovascular, anti-depressant, acne, blood pressure, supplements, etc.)*

YesNo
If yes, please list all oral medications:*

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Are you currently using any topical Retinoid prescriptions or other topical medications? (include tretinoin, Retin-A, Isotretinoin, Accutane, Renova, Differin, Tazorac, Avage, EpiDuo, Ziana, Hydroquinone, Benzoyl Peroxide, Metrogel, Efudex, Cortisone, Antifungal, etc.)*

YesNo
If yes, list all topical medications and for how long:*

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Are you currently undergoing isotretinoin therapy (Accutane)?*

YesNo
If yes, dosage and frequency:*
Have you ever had a cold sore/fever blister?*

YesNo
If yes, when was your last cold sore/fever blister?*
For Women Only

Gentlemen, please skip to Life Style
Do you have regular periods?*

YesNo
Going through menopause?*

YesNo
Endometriosis?*

YesNo
Poly cystic ovaries?*

YesNo
Are you trying to become pregnant?*

YesNo
Are you in a fertility program?*

YesNo
Are you pregnant or lactating?*

YesNo
Have you ever been pregnant?*

YesNo
During pregnancy, did you experience hyperpigmentation or a pregnancy mask?*

YesNo
Have you had a hysterectomy?*

YesNo
If yes to hysterectomy, partial or full?
Lifestyle
What is your occupation?*
Please check all that apply to your occupation:*

Air TravelHazardousPhysicalSedentaryUV ExposureN/A to all
Rate your level of stress on a scale of 1 to 5 (lowest to highest)*
What are your hobbies?*
Please check all that apply to your personal time:*

Air TravelSportsSedentaryPartyUV ExposureN/A to all
Daily/Weekly Exercise routine*
Do you smoke?*

YesNo
If smoker, how much/how often?*
How many hours of sleep per night?*
Alcoholic beverages per day/week:*
Do you experience pain?*

YesNo
If pain, where/how often?*
Skin Procedure History
Have you seen a Dermatologist specifically for a skin problem or skincare?*

YesNo
If yes, when did you see the Dermatologist and for what reason?*
Are you currently under any other physician's or skin therapist's care for your skin?*

YesNo
If under another physician/skin therapist for skincare, please detail reason:*
Have you ever had a skin lesion removed by a physician?*

YesNo
If yes, anatomical location of lesion:*
Do you currently use or receive depilatories or waxing? Laser hair removal?*

YesNo
If yes to any hair removal, when last used?*
Have you previously had any of the skin procedures below? If not, please skip to Skin Product History:*

YesNo
Microdermabrasion

YesNo
If Microdermabrasion yes, procedure date
Chemical Peels

YesNo
If Chemical Peels yes, type and date
Phototherapy (1PL)

YesNo
If Phototherapy yes, type and date
Laser Resurfacing

YesNo
If Laser Resurfacing yes, type and date
Radiofrequency

YesNo
If Radiofrequency yes, type and date
Dermabrasion

YesNo
If Dermabrasion yes, type and date
Cosmetic Surgery

YesNo
If Cosmetic Surgery yes, type and date
Cosmetic/Surgical Implants

YesNo
If Implants yes, type and date
Permanent Makeup

YesNo
If Permanent Makeup yes, type and date
Fillers: Collagen/ Botox/ Dermal

YesNo
If any Fillers/Botox, type and date
Skin Product History
Previous skin care brands used in the last five years:*
Have you ever used a product and had a bad reaction or sensitivity?*

YesNo
If yes, explain reaction/sensitivity*
Have you done aggressive exfoliation to your skin in the last 2 weeks?*

YesNo
If yes, explain type of exfoliation*
Current Skin Care Products:
Cleanser:*
Night Moisturizer:*
Exfoliant:*
Eye Cream:*
Toner:*
Masque:*
Serum:*
Sunscreen:*
Moisturizer:*
Make-up:*
Skin Type and Conditions
Describe your skin: (check all that apply)*

NormalDryT-Zone CombinationThickThinSaggyFirmOilyAcneicComedones/BlackheadsMilia/WhiteheadsCystsBreakoutsAcne-scarredLarge PoresSmall PoresFlorid (Ruddy)N/A to above
Describe your skin continued*

RosaceaFreckledSun-damagedMelasmaHyperpigmentationHypopigmentationUneven/blotchyMatureWrinkledSallowPatchy DrynessPsoriasisDehydrated/lacking moistureAsphyxiatedTelangiectasia/broken surface capillariesSensitiveSensitizedN/A to above
Is your skin pigmentation (skin discoloration)*

EvenUnevenBirthmarksPregnancy Mask
Any acne breakouts? (include blackheads, whiteheads, enlarged pores, pustules, cysts)*

YesNo
If yes, list all lesions*
Do you experience breakout during or around your menstrual cycle?*

YesNo
Does your skin ever get flaky or itch? Or feel tight and dry?*

YesNo
If yes to flaky, itch, tight, and/or dry, how often?*
How long after cleansing does your skin start feeling oily again?*

Within 1-2 hoursAlways feels oily and uncomfortableWithin 6 hoursThe next day or never
Do you flush or redden easily when eating spicy food, drink alcohol, or go in the sun?*

YesNo
Does wind or rough fabric irritate your skin?*

YesNo
Do you have difficulty healing from a cut or a burn?*

YesNo
Do you currently have a sunburn/windburn/red face?*

YesNo
Have you ever been diagnosed with Rosacea?*

YesNo
If yes to Rosacea, when was the diagnosis made?*
What are the top three changes you would most like to see in your skin? type here* type here* type here*
Please describe any additional medical or non-medical treatments not identified above:

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I certify that the information I have given above is true and correct. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing mis- information may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the skin therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release Bella Donna Skin Studio and/or skin therapist from liability and assume full responsibility thereof.
Client Signature:*

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Date*

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Skin Therapist Signature:

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Date

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Please verify that you are human*
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Bella Donna Skin Studio

Nutritional Information

Sun Exposure and Genetic History

General Health and Medical History

For Women Only

Lifestyle

Skin Procedure History

Skin Product History

Current Skin Care Products:

Skin Type and Conditions