Justified Skin Esthetics
Skin Consultation Form
Contact / personal information
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
Referral/ how did you find me?
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 year?
*
Yes
No
If yes to the previous question, please list any surgeries you had in the last Year.
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??
*
What changes are you seeking during this service? (Relaxation, address dark spots, etc…)
At what age did you notice your skin change?
*
What does your skin feel like in your T-Zone (forehead to nose)?
*
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
How much water do you consume daily?
*
In a few sentences, describe your diet on a daily basis:
*
How many caffeinated drinks do you have daily?
*
How much alcohol do you consume on a weekly basis?
Do you sunbathe or participate in outdoor activities? If yes, please list the activity(ies).
*
Do you use SPF/ sunscreen?
*
Yes
No
Have you ever had any kind OF chemical exfoliant such as Chemical peels? If so, were they done in a medical setting?
Do you currently follow a skincare routine?
*
Yes
No
What skin care products are you currently using?
Take a photo of your skin (Not a requirement)
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
After washing your face, how soon do you experience an oily shine?
Almost immediately
Mid-day
End of day
N/A
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
Date
-
Month
-
Day
Year
Date
Signature
Clear
Submit
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