Client Questionnaire
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Age
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Ethnicity
Please indicate if you have used any of the medications or drugs listed below in the last 2 years, when they were used and for how long you used them.
Rows
when
how long
medication
when
how long
Antibiotics (oral)
Antibiotics (topical)
Accutane
Benzoyl Peroxide
Retin-A, Tazorac, Differin
Thyroid medication
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Please list any other medications or drugs listed that you have used in the past 2 years and include when they were used, and for how long you used them:
Medical history (please check all that apply)
Herpes Simples
Eczema
Psoriasis
Hepatitis
Cancer
Staph Infection/MRSA
HIV/AIDS
Thyroid Problems
Hormone Problems
Hysterectomy
Ovar(ies) Removed
Pacemaker
Hemophilia
Lupus
Anemia
High Blood Pressure
Diabetes
Metal Pins in Body
Your Primary Care Physician Name and phone number:
Are you under a dermatologist's or other physician's care?
yes
no
if yes, doctor name and phone number
Have you ever had any reaction to any products or anything you have put on your face?
yes
no
If yes, what products?
Please check any of these you are allergic to
sulfur
aspirin
latex
list any other allergies you know of:
Do you smoke/vape
yes
no
If yes, what do you smoke
Do you fabric softner or fabric softener sheets in the dryer?
yes
no
Do you swim in a chlorinated pool?
yes
no
Do you work around chemicals, tars, oils, grease or inks?
yes
no
Occupation:
Do you work nights?
yes
no
Are you currently under a lot of stress?
yes
no
Whats your stress triggers: job loss, new job, wedding, death in the family, or close friend, graduations, heavily scheduled, others?
Do you use birth control pills, shots or use an IUD
yes
no
in which do you use?
what brand of pill?
Are you pregnant?
yes
no
Do you have shaving irritation on your face?
yes
no
What type of razor do you use for shaving (i.e, double blade, triple blade, rotary)
DIET - DO YOU CONSUME THE FOLLOWING?
Rows
how often per week
fast food
processed food
salty snacks
mil/yogurt
cheese
whey or soy protein
peanut butter
peanuts
sushi
kelp and seaweed
miso soup
soy
vitamins/supplements
seafood
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Have you ever used any Face Reality Skincare products?
yes
no
If yes, please list the products:
Are you still currently using Face Reality Skincare products
Products currently using - please provide products names
Rows
product name
brand
cleanser
toner
serum
moisturizer
sunscreen
mask
foundation
blush
exfoliant Iacid, serum, scrub)
acne medication
anything else?
Please tell me about your current skincare regiment - what products you use AM/PM, how often, etc
Other treatments: what else have you done for your skin in the last 90 days:
Rows
when
where
chemical peel
microdermabrasion
dermabrasion
laser hair removal
laser rejuvenation/resurfacing
skin cancer removal
facial waxing
electrolysis
other
How often do you get regular facials?
Please describe your skin -any history of or present acne, rosacea, melasma, ecxzema, psoriasis, or other diagnosed skin condition:
Please describe how you'd like your skin to look:
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Should be Empty: