Acne Client Questionnaire
Esthetics With Me
Client Questionnaire
Name
Age
Ethnicity
Address
Address
Street Address Line 2
City
State
Zip
Cell Phone
Format: (000) 000-0000.
Email
example@example.com
Medication
Rows
When
How Long
Antiobiotics
Accutane
Benzoyl Peroxide
Retin A
Cream or Gel?
Tazorac
Differin
Azelex
Avita
Cleocin-T
E-mycin-T
Copaxone
Corticosteroids
Quinine
Other Meds
Androstendione
Testosterone
Progesterone
Thyroid
Gonadotrophin
Danzol
Cyclosporin
Lithium
Isoniazid
Immuran
Disulfuram
Dilantin/Tegretol
Steroids
Marijuana
Cocaine/Speed
Medical History (Please check all that apply)
Rows
Check all that apply
Herpes Simplex
Eczema
Psoriasis
Hepatitis
Cancer
Staph Infection/MRSA
HIV/AIDS
Thyroid Problems
Hormone Problems
Hysterectomy
Ovary(ies) Removed
Pacemaker
Hemophilia
Lupus
Anemia
High Blood Pressure
Diabetes
Metal Pins in Body
Your Primary Care Physician:
Physician Phone
Format: (000) 000-0000.
Are you under a dermatologist's or other physician's care?
Yes
No
If yes, doctor's name:
Lifestyle Considerations - Have you ever had any reaction to any products or anything you have put on your face? Yes
No
Yes
If yes, what products?
Please check any of these you are allergic to:
Sulfur
Aspirin
Latex
List any other allergies you know of
Do you smoke?
Yes
No
Do you use fabric softener or fabric softener sheets in the dryer?
Yes
No
Do you swim in a chlorinated pool?
Yes
No
Do you work around chemicals, tars, oils, grease or inks?
Yes
No
Occupation
Do you work nights?
Yes
No
Are you currently under a lot of stress? Yes No common stress = job loss, new job, wedding, romantic breakup, death in the family or close friend, graduation, difficult home life, long commute, heavily scheduled)
Yes
No
Women: Do you use birth control pills, shots or use an IUD?
Yes
No
If so, which do you use?
What brand of pill?
Are you pregnant or nursing?
Yes
No
Men: Do you have shaving irritation?
Yes
No
What type of razor do you use for shaving?
Diet - Do you consume the following?
Rows
Check all that apply
Weekly?
Fast Food
Processed Food
Salty Snacks
Milk / Yogurt
Cheese
Whey or Soy Protein
Peanut Butter
Peanuts
Sushi
Kelp and Seaweed
Miso Soup
Soy
Vitamins
Seafood
Products Currently Using - Please Provide Product Name
Rows
Product
Cleanser
Toner
Serum
Moisturizers
Sunscreen
Mask
Foundation
Blush
Exfoliant (acid, serums, scrubs)
Acne Medications
Anything Else?
Other Treatments: What else have you done for your skin in the last 90 days? Leave blank if N/A
Rows
When?
Where
Chemical Peels
If so, what kind:
Microdermabrasion
Dermabrasion
Laser Hair Removal
Laser Rejuvenation/Resurfacing
Skin Cancer Removal
Facial Waxing
Electrolysis
Other:
How did you hear about us?
Signature
Date
-
Month
-
Day
Year
Date
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