Skin Health Questionaire

1
Name* This field is required.
First Name
Last Name
2
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Date of Birth* This field is required.If under 18 a parent or guardian must sign a consent for treatment prior to service.
Date
Month
Day
Year
4
Client Information
Please enter your phone
Please Select
Please Select
Female
Male
Not Listed
Gender
Please enter your email
Occupation
Emergency Contact - Name and Phone Number
5
ReferralHow did you hear about us? We offer referral rewards!
6
Skin Care Professional* This field is required.Who is your service with?
Brandie Humphrey
7
Which Are Your Skin Concerns?
Acne
Acne Scarring
Age Spots
Broken Capillaries
Dehydrated Skin
Dry Skin
Enlarged Pores
Fine Lines and Wrinkles
Hyperpigmentation
Ingrown Hairs
Scars
Stretch Marks
Other
8
If Other, Please Explain
9
How Would You Describe Your Skin?
Normal
Dry
Oily
Combination
Reactive
Sensitized
Sensitive
Sun Damaged
Dehydrated
Rosacea
10
Do You Experience Any of the Following?
Flakiness
Tightness
Redness
Excessive Oily Shine During the Day
Blush Easily
Bruise Easily
11
Where Do You Fall On the Fitzpatrick Scale?Please answer on the following screen.
12
Where Do You Fall On The Fitzpatrick Scale?* This field is required.
Type 1 - Light, Pale, White (Always burns, Never tans.)
Type 2 - White, Fair (Usually burns, Tans with difficulty)
Type 3 - Medium, White to Olive (Sometimes mild burns, gradually tans to olive.)
Type 4 - Olive to Medium Brown (Rarely burns, Tans with ease to a Moderate Brown.)
Type 5 - Brown to Dark Brown (Very rarely burns, Tans very easily)
Type 6 - Dark Brown, Black (Never burns, Tans very easily, Deeply Pigmented)
Choose one of the following
13
Have You Ever Had a Facial?
YESNO
14
How Was Your Facial Experience?
Did you have any skin reactions?
Was there anything you did not like about the Facial?
How many Facials do you have per year?
15
What is Your Current Skin Regimen?
Soap and Water Only
Cleanser
Moisturizer
Exfoliation
Toner
Sun Block Everyday
Masque
Other
16
Have You Ever Had:
Botox
Chemical Peels
Facial Surgery
Microdermabrasion
Cosmetic Surgery
Hydradermabrasion
Collagen Injections
Laser Resurfacing
Dermaplaning
Microneedling
Tattoos/Piercings
17
If Yes, How Recently? Any Complications?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
18
How Does Your Skin Heal?
Fast
Scars
Pigments
19
What Medications, (Including Vitamins/Supplements) do you take presently?* This field is required.
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Normal
Small
Ok
Ok
20
Have You Ever Used:
Accutane
Retin-A
Renova
Topical Antibotics
Differin
Tazarac
Hydroquinone
21
If Yes, When and For How Long?* This field is required.
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Small
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Ok
22
Have You Ever Had Any Of The Following In The Past?Lots of things can affect our skin. Answering this question will help us get a better understanding of your overall skin health so we can help you reach your skin goals. Some of the conditions listed below may be contraindications for some of our services.
Acne
Allergies
Arthritis or Bursitis
High Blood Pressure
Low Blood Pressure
Breast Implants
Cancer
Cholesterol
Claustrophobic
Diabetes
Keloids
Eczema
Epilepsy
Hay Fever
Headaches
Heart Disease/ Conditions
Fluid Retention
Hepatitis
HIV/AIDS
Infections
Lupus
Menopausal
Metal Implants
Phlebitis
Serious Injury
Sleep Problems
Thyroid
Varicose Veins
TMJ
Cataracts
Sore (Herpes Zoster/Shingles)
Family History of Skin Cancer
Other
23
Please List ALL Allergies* This field is required.Some of our products contain nuts and other allergens.
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Large
Normal
Small
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Ok
24
If Other, Please List Here
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Normal
Small
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Ok
25
Have You Ever Had A Reaction or Sensitivities to:
Cosmetics
Metals
Medications
Food
Fragrance
Airborne Particles
Skin Care Products
Latex
Essential Oils
Other
26
If Other, Please Explain
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Large
Normal
Small
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Ok
27
Women
Yes
No
Are you taking oral contraceptives?
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Are you pregnant or trying to get pregnant?
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Are you taking hormone replacement?
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Do you experience hormone imbalances?
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Are you taking oral contraceptives?
Are you pregnant or trying to get pregnant?
Are you taking hormone replacement?
Do you experience hormone imbalances?
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
Yes
Row 2, Column 0
No
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Yes
Row 3, Column 0
No
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28
What is Your Stress Level?
29
Lifestyle and Diet
Yes
No
Do you normally sleep well?
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Do you regularly exercise?
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Do you have food intolerances?
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Do you follow any special diet?
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Do you drink caffeine?
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Are you exposed to substances that may irritate your skin?
Row 5, Column 0
Row 5, Column 1
Do you sunbathe, use a tanning bed or have significant sun exposure?
Row 6, Column 0
Row 6, Column 1
Do you normally sleep well?
Do you regularly exercise?
Do you have food intolerances?
Do you follow any special diet?
Do you drink caffeine?
Are you exposed to substances that may irritate your skin?
Do you sunbathe, use a tanning bed or have significant sun exposure?
Yes
Row 0, Column 0
No
Row 0, Column 1
Yes
Row 1, Column 0
No
Row 1, Column 1
Yes
Row 2, Column 0
No
Row 2, Column 1
Yes
Row 3, Column 0
No
Row 3, Column 1
Yes
Row 4, Column 0
No
Row 4, Column 1
Yes
Row 5, Column 0
No
Row 5, Column 1
Yes
Row 6, Column 0
No
Row 6, Column 1
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30
In Our Treatment Program, It May Be Necessary To Recommend Alterations or Additions To Your Home Care Regimen; Would That Be Okay?
YESNO
31
Your Esthetician will recommend the appropriate schedule for future facial treatments or referrals in order to achieve your skin improvement goals.
32
Media ConsentDo you consent to your Esthetician taking photographs and/or videos during your service for records of your skin health progress? (Privately filed)
YESNO
33
Media ConsentDo you consent to your photographs or videos being used for social media or advertisments?
YESNO
34
POLICIES

1. We require 48-hours notice for cancellations.

2. If you are not satisfied with your service or products, please contact your skin care professional within 24-hours after your appointment so that the situation may be corrected. It is our policy to provide you with the best professional service and products customized for your skin condition.
35
I Full Name , do fully understand all the questions above and have answered them all correctly and honestly. I understand that the services offered are not a substitute for medical care. I understand that the skin care professional will completely inform me of what to expect in the course of treatment and will recommend adjustments to my regimen if deemed necessary. I also am aware that individual results are dependent upon my age, skin condition, and lifestyle. I agree to actively participate in following appointment schedules and home care procedures to the best of my ability, so that I may obtain maximum effectiveness. In the event that I may have additional questions or concerns regarding my treatment or suggested home product routine, I will inform my skin care professional immediately.

I release and hold harmless the skin care professional, Brandie Humphrey, Posh Salon and Day Spa and the staff harmless from any liability for adverse reactions that may result from this treatment.
36
SignatureI have read and understand all of the foregoing information.
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