Skin Health Questionnaire

CIRCADIA
Advanced Professional Skincare
CONFIDENTIAL SKIN HEALTH QUESTIONNAIRE
Today's Date

MonthDayYear
Date
First Nome
Last Name
Street
Apt. #
City
State
Zip
Dermatologist/physician
Emergency Contact
Your occupation
E Moil
Friend Skin Care Professional Name:
Skin Care Professional Name
1. What is the reason for your visit today?
2. What special areas of concern do you have?
EXPECTATIONS and HISTORY
3. Which conditions would you like to improve?

ACNEACNE SCARRINGAGE SPOTSENLARGED PORESFINE LINESHYPERPIGMENTATIONBROKEN CAPILLARIESSTRETCH MARKSSURGICAL/FACIAL SCARSOther
4. Have you ever had a facial treatment ?

YesNO
5. What was your experience?
6. How would you describe your skin?

NormalDryOilyCombinationSensitiveSun Damaged
7. How would you rate your skin? (Circle one)

Always burns, never tansAlways burns easily, tans slightlyBurns moderately, tans graduallySeldom burns, always tans wellRarely burns, deep tanNever burns, deeply pigmented
8. Do you ever experience (Mark all that apply)

Flakiness?Tightness?Redness?Excessive oily shine during the day?
9. What is your present skin regimen?

Soap & water onlyCleanserTonerMasqueMoisturizerExfoliationSun Block every day
10. Are you ever exposed to chemicols. ols. or other coustic substances that may oggravate your skin?
10. Are you ever exposed to chemicals, oils, or other coustic substances that my aggravate your skin?

YesNo
If yes, what are they?
11. Do you blush easily?

YesNo
If yes, what are they contributing factors?

EmotionsFoodsTemperature ChangesOther
12. Do you

Sun bathe?Use tanning bed?
How often?
13. Have you ever had

PeelsMicrodermabrasionFacial surgeryCosmetic surgeryBotoxCollagen InjectionsLaser resurfacing
How recently?
14. Are you under treatment for any current skin condition?

YesNo
If yes, what?
15. Does your skin heal

FastScarsPigments
16. Do you bruise easily

YesNo
17. Do you get sores/blisters (Herpes Zoster/Shingles)?

YesNo
18. What medications/hormone replacement/vitamins do you presently take?
19. Have you ever used:

AccutaneRetin-ARenovaTopical AntibioticsDifferinTazaracHydroquinoneAlpha Hydroxy Acids
If yes, when and for how long?
20. Any personal or family history of cancer?

YesNo
If yes, provide details below
21. How would you describe your overall health?

ExcellentGoodFairPoor

22. Have you ever had any of the following

	YES	NO	High	Low	Normal
Acne
Allergies
Arthritis or Bursitis
Blood Pressure
Breast Implant
Cancer
Cataracts
Cholesterol
Claustrophobic
Diabetes
Diarrhea/ Constipation
Eczema
Eplilepsy
Hay Fever
Headaches
Heart Disease/Conditions
Hepatitis
HIV/AIDS
Infections
Lupus
Menopausal
Metal Implants
Pace Maker
Phlebitis
Serious Injury
Sleep problems
Thyroid
Varicose Veins
Do you Smoke?
Do you wear contact lenses?

23. Have you ever had a reaction to:

CosmeticsMetalsMedicationFoodFragranceAirborne ParticlesOther
When
What

24. For Women:

	Yes	No
Are you taking oral contraceptives?
Are you pregnant or trying to get pregnant?
Are you taking hormone replacements?
Do you experience hormone imbalances?

For Men:

	Yes	No
Do you shave with an electric shaver? (yes for electric/ No for razor)
Do you experience skin breakouts?
Do you have ingrown hair?

1. Is your stress level

HighMediumLow
2. Do you normally sleep well?

YesNo
3. Do you regularly exercise?

YesNo
4. Do you have a food intolerance?

YesNo
If so, what are they?
5. Do you follow any special diet?

YesNo
6. How many glasses of water do you consume daily?
7. How many cups of caffeine-type beverage (coffee, tea, soft drinks) do you consume daily?

1-3 cups4 or more
8. In our treatment program, it may be necessary to recommend alterations to or additions in your home care regimen; would that be OK with you?

YesNo
Your practitioner will recommend the appropriate schedule for future focial treatments or physician referral in order to achieve your skin improvement gools.
INFORMED CONSENT RELEASE
I ___________________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 necessory. I also am aware that individual results are dependent upon my age, skin condition, and Mistyle. I agree to actively participate in following oppointment schedules and home care procedures to the best of my obility. so that I may

Circadia by Dr. Pugliese, Inc.
obtain maximum effectiveness. In the event that I may have additional questions or concerns regarding my treatment or suggested home product routine. will inform my skin care professional immediately.

I release and hold harmless the skin care professional [insert your name [insert business name), and the staff harmless from any liability for adverse reactions that may result from this treatment.

1. We require 48-hours notice for cancellations. Cancellation for Monday must be phoned in on the Friday before. 2. If you are not satisfied with your service or products. please contact your skin care professional within 24- hours ofter your appointment so that the situation may be corrected. If is our policy to provide you with the best professional service and products customized for your skin condition.

I have read and understood oll of the foregoing information
Client Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

CIRCADIA

CONFIDENTIAL SKIN HEALTH QUESTIONNAIRE

INFORMED CONSENT RELEASE