Justified Skin Esthetics
Skin Consultation Form
Contact / personal information
Please fill out this form to the best of your ability. This helps me understand where your skin is currently and how I can begin to address your concerns.
Name
*
First Name
Last Name
Suffix
Address
*
Street Address
Street Address Line 2
City
County
Zip code
Phone Number
-
Area Code
Phone Number
E-mail
*
example@example.com
How did you hear about justified skin Esthetics?
*
Were you referred by someone? If yes, please provide their name here
Health questionnaire
Have you ever been under a dermatologist or physician's care? If yes, when?
*
Have you undergone any surgery in the last two year?
*
Yes
No
If yes to the previous question, please list any surgeries you had in the last two Years,
Do you have any metal implants, pacemakers, or piercings? If yes, please list.
*
Please list any medications / supplements / vitamins you are currently taking
*
Please list any allergies you have:
*
Do you wear contact lenses?
*
Yes
No
Do you smoke?
*
Yes
No
Occasionally
On a scale of 1-5, how would you rate your stress? (1 = low, 5 = high)
*
Please select any medication you are currently using or have used:
*
Retinol
Glycolic Acid
Salicylic Acid
Topical Steroids
Benzoyl Peroxide (BPO)
Topical Antibiotics
Roaccutane
N / a
Other
Reproductive health
Please select N/A for anything that does not apply
Are you currently due for or on your menstrual cycle?
*
Yes
No
N/A
Are you currently or trying to become pregnant?
*
Yes
No
N/A
Are you taking any forM of birth control?
*
Yes
No
N/A
Are you currently lactating or breastfeeding?
*
Yes
No
N/A
Addressing Your skin
Let's learn about your skin:
What are your skin care goals??
*
Do you currently follow a skincare routine?
*
Yes
No
What skin care products are you currently using?
After washing your face, how soon do you experience an oily shine?
Almost immediately
Mid-day
End of day
N/A
What is skin goal the goal you’d like to accomplish in this appointment (Relaxation, address dark spots, etc…)
*
At what age did you notice your skin change?
*
Do you use SPF/ sunscreen?
*
Yes
No
Please select any skin concerns you believe you are experiencing:
*
Acne
Sensitivity
Oiliness
Dry
Signs of aging / Wrinkles / Fine lines
Blackheads / Whiteheads
Dehydrated
Uneven Skin tone / dark spots
Sun Damage
Rosacea
Flaky Skin
Broken Capillaries / Broken Veins
Peeling skin
Other
Do you sunbathe or participate in outdoor activities? If yes, please list the activity(ies).
*
Take a photo of your skin concerns in advance (Not a requirement)
If you’re under a dermatologist’s care, what has your dermatologist prescribed you?
What does your skin feel like in your T-Zone (forehead to nose) area?
*
Do YOu exercise?
Yes
no
Occasionally
Inconsistently
What is your daily water intake?
*
what is your daily caffeine intake?
*
How much alcohol do you consume on a weekly basis?
In a few sentences, describe your diet on a daily basis (please provide details):
*
Have you ever had any kind OF chemical exfoliant such as Chemical peels? If so, were they done in a medical setting?
Preferences
What type of massage do you prefer?
*
Light
Medium
Firm
What is your pain threshold?
*
Low
Average
High
Have you ever experienced claustrophobia?
*
Yes
No
What Music genre would you prefer to listen to during your service? (Optional)
Would you like to request a silent appointment? (Music and silence, or complete silence. totally up to you)
Sign form
See you at your appointment!
Date
-
Month
-
Day
Year
Date
Signature
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