Client Skin Care History

Client Skin Care History

Many facial treatments involve botanicals and many skin care conditions are related to the foods we eat and our environment. Each question, though it may seem irrelevant, can affect what treatments might be harmful and what products will give you optimal results. Please take the time to thoroughly answer each question. Form must be filled out at least 24 hrs before appointment.
NAME*
CELL PHONE*
EMAIL*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate*

MonthDayYear
Gender*

FemaleMale
How were you referred? *
What would you like to achieve from your treatment?*
During your treatment would you prefer to: (check all that apply)

Relax in silenceChatBe educated about skinOther
Have you ever had a facial treatment before?*

YesNo
How would you characterize your skin? Check all that apply.*

NormalDryOilyMild AcneModerate AcneSensitiveMatureSun DamagedSunburned (Currently)
Skin Type: Which statement best describes your skin type?*

Type l Fair- Always burn, never tanType ll Light-Burn easily, tan lightlyType lll Fair to Olive- Burn moderately, tan moderatelyType lV Light Brown-Rarely burn, tan easilyType V Dark Brown- Rarely burn, tans easilyType Vl Dark Brown to Black- Never burns, tans easily
If you could change 2 things about your skin what would they be?
What size spa wrap would fit you best?
Have you had Botox, filler, or any injections in the last 2 months?*

YesNo
Have you had a chemical peel, laser treatment, facial wax, micro-dermabrasion, microneedling, dermaplaining or other facial treatment in the past month?*

YesNo
Current Skin Regimen
Do you wash your face? (Check all that apply)

Yes, if I get a break outNo, unless I'm in the showerYes, but not EVERY morningYes, but not EVERY nightYes, every nightYes, every morningOther
When you do wash, what do you wash your face with?*

SoapCleanserOther
Please list both brand name and the specific name of product for any products you use regularly.

Ex: Neutrogena, Sensitive skin moisturizer
Cleanser Brand and Specific Name
Toner Brand and Specific Name
Day Moisturizer Brand and Specific Name
Night Moisturizer Brand and Specific Name
Exfoliator/Scrub Brand and Specific Name
Mask Brand and Specific Name
Eye Product Brand and Specific Name
Other serums, etc.
Do you wear makeup?
Do you wear sunscreen?

My moisturizer or foundation has SPF and I think that's sufficient.Yes! I put it on every morning.Yes, but only if I'm going to be in the sun.Sometimes, if I remember.Nope, never.
Facial Sun protection: Brand and SPF level
Anything else you use regularly on your skin?
Where do you most often buy your skincare products?*
Have you ever had an allergic reaction to any of the following? Check all that apply.*

GlutenNutsSoyShellfish/SeaweedFruits (any-cherry, raspberry, acai, etc.)MilkBody waxSkin care productsSkin care treatmentsNickleLidocaineHydrocortisoneBeesNoneOther
If you marked any allergies please list specifics.
Do you use any topical Retinoids or other skin related topicals?*

Retinal, Retinol, Vitamin ASteroids/Cortisone CreamsBenzoyl PeroxideAcids (lactic, glycolic, salicylic)HydroquinoneNoOther
Have you taken Accutane or used Retin-A/Renova or any topical prescription in the last 12 months?

YesNo
Lifestyle
What is your occupation?
How many 8 oz glasses of water do you drink daily?
Do you exercise regularly?

YesNo
What is your stress level on a scale from 1 to 10 if 1 = low stress, 10 = high stress?
How often are you out in the sun?
Are you sensitive to fragrances such as essential oils?*

YesNoOther
Are you pregnant?*
Are you currently on birth control?

YesNo
Are you experiencing any menopausal symptoms?

YesNoBeen There, Done That!
Do you smoke or vape?

YesNo
How many hours of sleep do you get each night?

Under 56-78-910+
Is there anything else you'd like me to know about you/your skin?
I have read, understood, and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any verbal or written disclosures.

I understand that withholding information or providing misinformation may result in contraindications, skin irritations, and/or a poor outcome from treatments received.

I understand that the treatments I receive at WMSkin are voluntary and I release this institution and/or the esthetician from liability and assume full responsibility thereof.

I understand that cancellations must be made MORE THAN 24 HOURS in advance of my appointment and that after 1 cancellation or no show a $50 deposit will be required for future bookings.
Client Name (Printed):*
Client Signature & Date*

Clear
Should be Empty:

Client Skin Care History

Current Skin Regimen

Lifestyle