Confidential Health Intake Form
Today's Date
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Month
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Day
Year
Date
Client Information
Name
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First Name
Last Name
DOB
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Month
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Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
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Please enter a valid phone number.
Email
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example@example.com
How did you hear about us?
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Lifestyle Questions
What is your average daily stress level (1-Low, 10- High)
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Please Select
1
2
3
4
5
6
7
8
9
10
How many hours of sleep per night?
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Do you meditate?
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Please Select
Yes
No
How many hours of weekly exercise?
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Types of exercise?
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How much water consumed daily?
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How much caffeine consumed daily?
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What does your weekly diet consist of?
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Do you drink alcohol?
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Please Select
Yes
No
How often?
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How does your body typically respond to alcohol consumption?
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Do you/did you smoke?
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Please Select
Yes
No
If applicable, when did you stop?
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How much UV exposure do you get weekly? (sun or tanning bed)
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Medical Information
Are you currently or have you ever been treated for any of the following? Check all that apply:
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Acne
Depression
High/Low Blood Pressure
Heart Disease
Epilepsy
Skin Disease/Irritation/Infection
Cancer
Diabetes
Cold Sores (Herpes Simplex)
Hormone Therapy
IVF
Autoimmune Conditions
Thyroid
Claustrophobia
None
Do you have any metal implants (Pacemaker, pins in bones)?
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Have you ever taken Accutane?
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Please Select
Yes
No
Are you using retinoids (Retin-A or Retinol)?
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Please Select
Yes
No
Have you ever applied Benzoyl Peroxide (OTC or prescription)?
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Please Select
Yes
No
List all (past or current) oral or topical medications:
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Please list all allergies:
Food
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Drug
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Environmental
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Please list and explain any past skin reactions or sensitivities
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Are you pregnant or lactating?
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Please Select
Yes
No
Are you trying to conceive?
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Please Select
Yes
No
Please elaborate on any of the above as necessary.
Skin Care Information
What skincare issues or concerns are you needing help with?
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What emotions do you feel about your skin concerns (worry, frustration, anger, depression, etc)?
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In what ways do you feel stuck with your skin results or lack thereof?
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What products and brands are you currently or most recently using?
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How are the results with these products?
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When was your last professional facial treatment or session?
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How you currently feel about the overall quality of your skin’s health? (1-Low, 10-High)
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Please Select
1
2
3
4
5
6
7
8
9
10
Do you feel comfortable in public without wearing makeup or cover-up?
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Please Select
Yes
No
What would you like to learn more about in terms of skin and skincare?
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In what ways are you hoping I can help you on your skincare journey?
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Thank you for completing this confidential intake form. This information will allow your skin care specialist to provide the best level of care, products and services.
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