Facial Treatment - Client Intake Form

  • Client Intake Form

    Facial Service
  • Format: (000) 000-0000.
  • Does your job require that you work outdoors?

  • Your Skincare Health

    Please answer all questions truthfully and to the best of your knowledge
  • Within the last year, have you been under a dermatologist’s or other physician’s care?*
  • Have you had any health problems in the past or present?*
  • Do you have any allergies?*
  • Have you ever had a body spa treatment before?*
  • Which of the following best describes your skin type?*
  • Do you have any special skin problems or concerns pertaining to your face or body?*
  • Have you ever had chemical peels, laser or microdermabrasion?*
  • Have you used an acne medication?*
  • Have you used any of the following hair removal methods in the past six weeks?*
  • Do you smoke?*
  • Do you exercise regularly?*
  • Do you follow a restricted diet?*
  • Do you have metal implants, a pacemaker or body piercings?*
  • Do you wear contact lenses?*
  • Do you sunbathe or use tanning beds?*
  • Do you drink more than 4 caffeinated beverages daily (coffee, tea, soft drinks)?*
  • Have you ever experienced claustrophobia?*

  • Your Skin

  • What skin care products are you currently using on your face? Please check all that apply.*
  • What skin care products are you currently using on your body? Please check all that apply.*
  • Have you ever had chemical peels, microdermabrasions, or any resurfacing treatments?*
  • Do you use Retin-A, Renova, Adapalene or any other prescription skin products?*
  • Are you currently using any products that contain the following ingredients?*
  • Have you ever experienced the following conditions on your skin?*
  • Do you burn easily in moderate sunlight?*
  • Do you suffer from sinus problems?*
  • Do  you ever experience burning, itching or stinging sensations on your skin?*
  • Do  you have a tendency to redness?*

  • Female Clients Only

  • Are you taking oral contraception?*
  • Are you pregnant?*
  • Are you lactating?*
  • Are you currently having or due for a menstrual cycle?*

  • Male Clients Only

  • Do you experience irritation from shaving?*

  • Questions to discuss every visit

  • Have you started any new medications since your last visit?
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  • Should be Empty: