RUDO Skin Esthetics Intake Form

Face & Body Intake Form

Please provide your information below. Thank you!
Today's Date

MonthDayYear
DateHourMinutesAM/PM Option
Full Name*
Please type first and last name.
D.O.B. (MM/DD/YYYY)*
Phone (DAYTIME)*
Email Address*
example@example.com
Occupation
How did you hear about us?*
Wellness Profile
Have you ever had any of the following conditions? (Please select all that apply)

AcneKeloidsConstipationRosaceaFibroidsDiabetesCold Sores/Fever BlistersPolycystic Ovarian Syndrome (PCOS)CancerHIV/AIDSLupusHeart ConditionsPacemaker/Metal ImplantsArthritisSeizuresSevere Headaches/MigrainesHepatitisBleeding Disorder (i.e. Anemia)Thyroid DiseaseSkin Disorder (i.e. Dermatitis)Other
Have you ever had an allergic reaction to any of the following? Please select all that apply)*

CosmeticsMedicineFood (incl. shellfish)AnimalsSunscreenDrugsIodinePollenAHAsFragranceLatexN/A
List any current medications (including OTC) and herbal supplements (including vitamins).*

Lifestyle Habits*

Rows	Intake Amount?	Frequency?
Water
Caffeine
Smoke
Illicit Drugs
Alcohol
Sugar
Dairy (does NOT include eggs)

Esthetics Information
How would you describe your skin?

NormalOilyDryCombination
Have you been under the care of a dermatologist within the past year?*

YESNO
If yes, please explain...
What are your top 3 areas of concern regarding your skin? (Please select up to 3)*

Breakouts/AcneBlackheads/WhiteheadsUneven Skin ToneSun DamageExcessive Oil/ShineWrinkles/Fine LinesDull/Dry SkinRosaceaBroken CapillariesRedness/RuddinessDehydratedSun, Liver, Brown SpotsOther
What skincare products do you use on a DAILY basis? (Please select all that apply)*

CleanserAM Corrective SerumToner/AstringentPM Corrective SerumAM MoisturizerExfoliantPM MoisturizerMaskSunscreenEye CreamEyelash/Brow TintingOther
Have you ever received the following skincare treatments and/or cosmetic procedures? (Please select all that apply)*

FacialsMicrodermabrasionRadiofrequencyChemical PeelsLaser Hair RemovalMicroneedlingDermaplaningEsthetic Laser Treatment (IPL, Fraxel, etc.)MicrochannelingPlatelet Rich Plasma (PRP)Facial UltrasoundLED TreatmentFacial Waxing/SugaringMicroblading/PMUEyelash/Brow Tinting
Have you received Botox, Restylane, Collagen or other injections in the last 6 months?*

YESNO
Do you currently or have you used in the last 3 months any products containing the following: (select all that apply)*

Retin-ARetinol/Vitamin A derivativeRenovaAHA (i.e. glycolic, lactic, malic acids)BHA (i.e. salicylic acid)Benzoyl PeroxideAccutaneHydroquinoneDifferinTazaracTopical AntibioticsTrentinoinAvageEpiDuoZianaOther
Are you currently taking birth control or have an IUD?*

YESNO
Are you currently pregnant or breastfeeding?*

YESNO
Are you currently undergoing any hormone therapies or taking any infertility drugs?*

YESNO
Are you currently experiencing Perimenopause or Menopause?

YESNO
Client Signature*
Should be Empty:

Face & Body Intake Form

Wellness Profile

Esthetics Information