Cosmetic interest form

Cosmetic Interest Questionnaire

Please provide the following information to receive a custom aesthetic treatment plan.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
E-mail*
example@example.com
Phone Number (Only include numbers)*

Area CodePhone Number
Instagram Handle*
@instagram
How did you find me?*

InstagramFacebookSearch engine (google, yahoo)Patient referral
Aesthetic Motivation
What is your primary motivation for seeking cosmetic treatment?
Event Date

MonthDayYear
Date
To what extent do you feel your feature(s) are currently ugly, unattractive or ‘not right’?*

Very ugly or 'not right'Markedly unattractiveModerately unattractiveSlightly unattractiveNot at all unattractive
How often do you do you deliberately check your feature(s)? Not accidentally catch sight of it.*

About 40 times or more a dayAbout 20 times or more a dayAbout 10 times or more a dayAbout 5 times or more a dayNever check
To what extent does your feature(s) currently cause you a lot of distress?*

Not at all distressingSlightly distressingModerately distressingMarkedly distressingExtremely distressing
Identity Assessment

I desire a facial structure that aligns with

	1	2	3	4	5

1 is Feminine, 5 is Masculine

Skin
Describe how your face feels when you cleanse & let it dry for 20 minutes without applying anything to it:*

TightNormalOily/ShinyIrritated/ Red
Describe your skin concerns:*

Acne ProneHyperpigmentation/ Dark SpotsFine LinesCystic AcneRosacea/ RednessHypopigmentatiomMiliaAcne ScarringSun DamageLarge PoresBroken CapillariesPatchy DrynessUneven/BlotchyNot Sure
Are you currently or have you previously received the following skin care treatments?*

Facial PeelMicrodermabrasionDermaplaningPermanent make-up/tattooing/microderm pigmentationLasersMorpheus, Profound, Sylfirm RadioFrequency MicroneedlingMicroneedlingNone
If so, when and what treatments?
Are you currently under the care of a Dermatologist?*

YesNopending appointment
Are you prescribed any RX topicals that you apply to you face?*

YesNo
If so, what are they?
List name, strength, dose and frequency of use.
Morning Skincare*
List your AM skincare in order of application
Do you have a product to reapply your sunscreen throughout the day?*

NoBrush-on Powder sunscreenSpray SunscreenCream Compact Sunscreen
Evening Skincare*
List your PM skincare in order of application
Are you currently using any skincare products that contain active ingredients (Glycolic/Salicylic Acid, Vitamin A)?*

YesNo
Has any skincare product ever caused a bad reaction?*

YesNo
If yes, what product and describe reaction:
Describe ingredient allergies, breakouts, rashes, etc
FACE
Please describe your face shape:*

RoundOvalSquareHeart Shape
Have you had surgery on your face or neck?*

YesNo
If yes, please describe the type of surgery & date:
Do you have any implants in your face?*

YesNo
Neuromodulators

Botox, Dysport, Xeomin, Daxi
Do you currently have any of the following static lines?*

Forehead WrinklesFrown LinesBunny LinesCrow's FeetNasolabial Folds (nose to mouth lines)Vertical Lip Lines (Smoker's Lines)Marionette Lines (concerns of mouth to jaw)None
Have you ever been treated with Botox/Dysport?Xeomin?*

YesNo
If so, have you had adverse effects from your neuromodulator treatment?
Do you clench your jaw or grind your teeth?

YesNoUnsure
Fillers

Restylane, Juvederm, RHA, Versa, Radiesse, Bellafill, Artefill
Have you ever been treated with any of the following?*

Hyaluronic Acid Dermal Filler (Juvederm, Restylane, Versa, RHA)Calcium Hydroxyapatite (Radiesse)Sculptra (PLLA)Silicone InjectionsBellafillArtefillOther
If so, please list when, what areas and the injector?
Have you ever had dermal filler dissolved?*

YesNo
Do you have history of cold sores or fever blisters?*

YesNo
Comments
Biostimulators

Sculptra, PRP, PRF, EzGel/Biofiller, Exosomes
Have you ever been treated with any of the following?*

Sculptra (PLLA)Hyperdilute Radiesse (CaHA)PRPPRFPRF EzGel or BioFillerExosomesNo
If so, when and what areas?
Take a Photo

Please stand in front of a window and take two photos without any makeup, filters or facial expression.
Facing the camera (anterior)*
Looking to the side (Profile)*
Goals & Outcomes
Describe your favorite features:*
Describe your primary concerns:*
Describe the outcome you would like to achieve from aesthetic treatments:*
Should be Empty:

Cosmetic Interest Questionnaire

Aesthetic Motivation

Identity Assessment

Skin

FACE

Neuromodulators

Fillers

Biostimulators

Take a Photo

Goals & Outcomes