• face reality TM

    face reality TM

  • Client Questionnaire

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • face reality TM

  • Image field 11

  • Medical History (please check all that apply)

  • Are you under a dermatologist’s or other physician’s care?
  • Format: (000) 000-0000.
  • Have you ever had a reaction to any products or anything you have put on your face?
  • Please check any of these you are allergic to:
  • Do you smoke?
  • Do you use fabric softener or fabric softener sheets in the dryer?
  • Do you work around chemicals, tars, oils, grease, or inks?
  • Do you swim in a chlorinated pool?
  • Do you work nights?
  • Are you currently under a lot of stress?
  • Image field 44
  • Women: Do you use birth control pills, shots or use an IUD?
  • Are you pregnant or nursing?

  • Diet- Do you consume the following?

  • Fast Food

  • Products Currently Using- Please Provide Product Names

    Exfoliant (acids, serums, scrubs)

  • face reality TM

  • Image field 58

  • Other Treatments: What else have you done for your skin in the last 90 days?

    Laser Rejuvenation/Resurfacing

  • Men do you have shaving irritation?
  • Do you consume the following?

  • Products Currently Using: Please Provide Product Names

  • Other Treatments: What else have you done for your skin in the last 90 days?
  • Should be Empty: