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Skin Health Questionnaire
Please complete and submit, you will then be redirected to our policies agreement
Contact Information
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred language
English
Spanish
Referred by
*
Expectations & History
Which conditions would you like to improve?
Dryness
Oiliness
Aging
Acne/Acne scarring
Age Spots
Enlarged Pores
Other:
If you chose other, please explain:
Have you had any facial waxing within the last 72 hours?
Please Select
Yes
No
Have you ever had a facial treatment?
Please Select
Yes
No
If yes, When was the last time?
Are you under treatment for any current skin condition?
*
Please Select
Yes
No
Are you currently pregnant?
Please Select
Yes
No
Are you taking hormone replacement?
Please Select
Yes
No
Are you on any medications or home care products that may affect your facial or waxing service? (Examples - Retinol or Vitamin A)
*
Please Select
Yes
No
Have you ever used any of the following?
Accutane
Retin-A
Renova
Topical Antibiotics
Differin
Tazarac
Hydroquinone
Alpha Hydroxy Acids
If yes, when and for how long?
How would you describe your skin?
Acne
Combination
Dry
Normal
Oily
Sensitive
Sun damaged
Other
If Other, how would you describe your skin?
Do you ever experience the following?
Flakiness
Tightness
Redness
Excessive oily shine during the day
What is your present skin regimen?
*
Soap and water only
Cleanser
Exfoliation
Toner
Mask/Masque
Moisturizer
Sunblock every day
Other
If other, Please explain:
Are you ever exposed to chemicals, oils, or other caustic substances that may aggravate your skin?
Please Select
Yes
No
Do you blush easily?
Please Select
Yes
No
If yes, what are the contributing factors?
Emotions
Food
Temperature Changes
Other
If other, Please list:
Do you
Sunbathe?
Use a tanning bed?
Have you ever had the following?
Peels
Microdermabrasion
Facial Surgery
Cosmetic Surgery
Botox
Collagen injections
Laser Resurfacing
If yes to the above, How recently?
What medications/hormone replacement/vitamins do you presently take?
Any personal or family history of skin cancer?
Please Select
Yes
No
Have you ever had any of the following? Past or Present.
Acne
Allergies
High/Low Blood Pressure
Cancer
Cataracts
Claustrophobic
Diabetes
Epilepsy
Hay Fever
Headaches
Heart Disease/Conditions
Metal Implants
Pace Maker
Thyroid
Varicose Veins
If yes above, please explain.
Do you smoke?
Please Select
Yes
No
Do you wear contact lenses?
Please Select
Yes
No
Have you ever had a reaction to
Cosmetics
Metals
Medication
Food
Fragrance
Airborne particles
Other
If other, please explain.
Lifestyle & Diet
What is your stress level?
High
Medium
Low
Do you normally sleep well?
Please Select
Yes
No
Do you have a food intolerance/allergies?
Please Select
Yes
No
If yes, to what?
Do you follow any special diet?
Please Select
Yes
No
How many glasses of water do you consume daily?
How many cups of caffeine-type beverages do you consume daily?
1-3
4 or more
Can your provider recommend products specifically for your skincare needs?
Please Select
Yes, please.
No thank you.
Is there anything else that you would like to let your provider know?
I fully understand all questions above have been answered correctly and honestly. I understand that the services offered are not a substitute for medical care. I understand that the skin care professional will inform me of what to expect in the course of the 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 will inform my skin care professional of any updates that need changed to my profile. I release and hold harmless, The Greenhouse and its practitioners, from any liability for adverse reactions that may result from this treatment. Agreeing below acts as my signature of consent.
*
I agree
I disagree
If you choose to share a photo of your current skin concerns, please upload here:
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