Skin Treatment Questionnaire
For Skin Services by Licensed Esthetician Allysa Johnston @ CAUSE
Name
*
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Any known allergies?
*
Asprin
Latex
Fruits
Shellfish
Fragrance/essential oils
Tree Nuts
Dairy
Sunscreen
Pollen
None
Other
Have you ever received any botox, filler or any chemical peels within the past 2-3 weeks?
*
Yes
No
Have you received any of these facial hair removal services in the last 7 days?
*
Waxing/sugaring
Threading
Laser/Electrolysis
Dermaplane
Shaving
No
List medications, supplements skin conditions, or health conditions I should be aware of.
Do you currently use:
*
Accutane
Retin-A
Prescribed topical cream
No
Unknown
Are you currently using any products that contain:
*
AHA (glycolic acid, lactic acid, etc.)
BHA (salicylic acid)
Vitamin A derivative (retinol/retonids)
Exfoliating scrubs
Unknown
No
What products do you currently use in your skin care routine? (if not using any, type none)
*
What would you say your skin type is?
*
Normal (no visible blemishes, fine pores, smooth texture)
Sensitive (reactive to fragrance, often irritated)
Combination (oily and dry patches, oily t-zone, hormonal breakouts)
Oily (enlarged pores, excessive oil)
Acne (cystic or nodules)
Dry (dull, visible lines and wrinkles, feels tight)
Have you ever experienced claustrophobia? (warm towels & facial steaming are used)
*
Yes
No
Do you?
*
Wear contact lenses
Have a pacemaker
Have metal implants
Smoke
Consume Alcohol
Consume Caffeine
Use Tanning Beds
None
What music would you prefer to listen to during your skin service?
Spa/Lo-fi Beats
Soft R&B
Folk/Acoustic
White Noise
Nature Sounds
No Preference
Other
Life is stressful- but your time with me shouldn’t be. If you just need some quiet time and would like this to be more of a “silent“ treatment with minimal talking, you can choose so below :)
Sleepy time 😴
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