Name
*
Phone
*
Email
*
DOB
*
Reffered by
Ethnicity
If you could change one thing about your skin what would it be?
What areas would you like to improve?
Wrinkles
Capillaries
Breakouts
Scarring
Texture
Acne
Firmness
Blackheads
Congestion
Pore size
Aging
Melasma/hyperpigmentation
Any known allergies to: cosmetics, food, medication, animals, pollens or metals?
*
Any Known Allergies to sulfur, Aspirin, or latex?
Do you use fabric softener or fabric softener sheets?
Yes
No
Do you swim in a chlorinated pool?
Yes
No
Do you work around tar, grease, oils, chemicals or ink?
Occupation - do you work nights?
Are you currently under a lot of stress? (Common stress is job loss, new job, death in the family, romantic breakup, graduation, heavily scheduled)
Women: do you use birth control pills, shots, or IUD? What brand of pill? Are you pregnant or nursing
Men: do you have shaving irritation ? What razor do you use?
Dietary supplements or vitamins?
*
Do you eat any of the following:
Fast foods
Processed -foods
Salty snacks
Milk/Yorgurt
Cheese
Whey or soy Protein
Peanut Butter
Peanuts
Sushi
Kelp or seaweed
Miso soup
Soy
Vitamins
Seafood
How much water do you drink daily?
*
List all skin products and/or acne meds currently using
Have they achived the results you want?
Yes
No
Do you use sunscreen?
Yes
No
Do You smoke?
Yes
No
Have you had in the past or present any of the following:
Heart problems
Hormonal imbalance
Diabetes
Cancer
Depression
Thyroid issues
Hysterectomy
Blood pressure
Other
Are you allergic to shellfish / seafood?
Yes
No
If other please specify
Have you had plastic surgery?
Yea
No
Are you currently using Retin-A, Retinol, AHA, BHA, or any other peeling agents?
Yes
No
If so, which ones?(please stop using them at least 3 days before appointment)
Do you suffer from claustrophobia?
Yes
No
Do you have the tendency to keloid scar?
Yes
No
Are You on any medications or antibiotics? If so, which ones?
Have you had or have any of the following:
Herpes Simplex
Ezcema
Psoriasis
Hepatitis
Cancer
Staph infection
HIV/AIDS
Thyroid problems
Hormone problems
Pacemaker
Hemophilia
Lupus
High blood pressure
Diabetes
Metal pins in body
Anemia
Hysterectomy
Have you done anything else to your skin recently? Botox, Laser, chemical peels, Facial Waxing, Skin cancer removal, or anything related? **Please keep in mind if you have done Botox, fillers, & Laser Hair Removal you must wait a minimum of 2 weeks before getting any treatment done**
Have you had covid?
Yes
No
Have you ever had a DMK enzyme Treatment?
On a scale of 1-10 (10 being the highest rating) How important is skin health to you?
On a scale of 1-10 (10 being the highest) how would you rate your current skin health?
Will you allow me to photograph/video for your own progress as well as publish in social media?
Yes
No
DATE
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ELECTRONIC SIGNATURE
*
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