Skin Treatment Intake
Todays Date
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Ok to Email?
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How did you hear about PowerHouse Esthetics?
Website/Online Search
Instagram
Facebook
Referral
Other
Specify Other or List Name of person who referred you
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Occupation
Skin Specifics
Your Skin Goals and Concerns:
Skin Type:
Normal
Dry
Oily
Sensitive
Combo
Do you have any of the following skin concerns? Please check all that apply:
Hyperpigmentation/Melasma/Sun Damage
Sensitivity/Rosacea/Redness/Flushing
Aging/Fine Lines/Wrinkles/Collagen Loss
Acne/Acne Scars/Blackheads/Pimples/Breakouts
Cystic Acne/Scarring
Uneven Skin Tone/ Uneven Texture/ Large Pores
Impaired Barrier Function/ Dryness/Dehydration/Flakiness
Ingrown Hair
Other
Have you ever had facials, chemical peels, microdermabrasion or any other resurfacing treatments?
Yes
No
If yes, was it within the last month?
Yes
No
Specify Treatment Type and Date of Treatment
Have you received any Botox, Juvederm, or any other dermal fillers in the last two weeks?
Yes
No
What skin products are you currently using including make-up? Please be as specific as possible, including brands and time of use (i.e AM or PM). Send a picture of your current skin care routine to (615)601-0745
Health Specifics
Have you experienced any of these health conditions in the past or present?
Hormone Imbalance
Cancer/ Systemic Disease
High Blood Pressure
Diabetes
Heart Problems
Arthritis
Autoimmune Disorder
Asthma
Epilepsy/ Seizure Disorder
Fever Blisters/ Cold Sores
Herpes
HIV/AIDS
Depression/Anxiety
Hepatitis
Headaches/ Migraines
Eczema
Dermatatis
Psoriasis
Other
Pregnant
Other Skin/Health Issues
Do you...?
Wear Contacts
Have a Pacemaker
Have Metal Implants
Have Body Piercings
Please list any medications, supplements or vitamins that you are currently taking
Are you using any of the following topical creams/oral medications?
Retin-A
Tretinoin
Differen
EpiDuo
Tazorac
Accutane
Clindamycin
Spironolactone
Benzoyl Peroxide
Any Form of Anti-aging Products
Do you have allergies or sensitivities to any food/medications/environment?
Yes
No
Please check all that apply
Aspirin
Nuts
Gluten
Ragweed
Lavender
Hydroquinone
Chamomile
Latex
Sunscreens
Fragrance
Fruits
Specify Allergens
Are you a Smoker?
Yes
No
Social
Do you drink more than 4 caffeinated beverages a day? ( Tea, Coffee, Soda, or Energy Drinks)
Yes
No
Have you experienced claustrophobia?
Yes
No
Please rate you stress level
Low
Medium
High
Are you pregnant or breastfeeding?
Yes
No
Any menopause symptoms?
Yes
No
Are you undergoing any Hormone Replacement Therapy?
Yes
No
Skin Improvement Commitment
Are you willing to take my professional recommendation for home-care products and treatments to better your skin?
Yes
No
On a scale of 1-10, how committed are you to achieving maximum results for your skin in terms of home-care products and in-office treatments?
Not at All
1
2
3
4
5
6
7
8
9
More Than Ever
10
1 is Not at All, 10 is More Than Ever
A typical skin-care regimen on average is 4 or more products. How many steps are you comfortable using in your home-care regimen?
Bare Minimum 1-3
A Good Start 2-4
A Complete System 4-6
Whatever it Takes 6-8
Skin-care is an investment, please specify if you have a budget need to work with?
Yes
No
In connection with my skincare services I am receiving from PowerHouse Esthetics I consent that photographs may be taken of me, or parts of my body under the following conditions: Photos may be used for marketing, or educational purposes, it is specifically understood that you will not be identifiable and your name will not be used.
Yes
Yes (no tags, eyes closed or covered)
No
Signature
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