Acne Client consultation
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
example@example.com
Occupation: ( this helps us understand the climate and environment you are working in)
Please list ALL medications, supplements/vitamins, birth control, or herbal remedies you currently take:*
Please list allergies or sensitivities:*
Please list Injuries or surgeries:*
Have you ever received professional skin care treatments - if yes please list when your last treatment was (not including with sbhstudio)
What do you consider your skin type?*Normal,Oily, Acne Dry, Aging, Combination, Sensitive, Rosacea
What is your current skin care regimen? AM/PM- please be very specific with product names/brands. Any other products used on the skin at all?*
Please list all makeup products used. Please be very specific with product names/brands.*
Please list shampoo and conditioner used. Please be very specific with product name/brand.*
How often do you wash pillowcases and makeup brushes/sponges?*
Please list the toothpaste that you use.*
Do you wear spf every day?*
Please check all that apply.* Pregnant, Breastfeeding, Postpartum, Neck Pain, Back Pain Headaches, High Blood Pressure Bruise Easily, Diabetes, Seizures Knee/Leg Pain Jaw Pain / Clenching/ Grinding, Metal Implants , Fibromyalgia Used Retin-A, Retinol, Tretinoin, Adapalene, Differen, within the past 10 days? Used Accutane within the past 6 months None of the above
Have you received any medical aesthetic treatments in the last 6 months? (botox, filler, etc.) If so, when? Do you have any underlying medical conditions your provider should be aware of?*
Do you have regular periods?*
Are you going through menopause?
Lifestyle —- Please indicate any of the following that apply to your diet.* Fast Food, Wheat Seafood , Excessive Salt your food, Milk/yogurt/cheese, spicy food, Peanut Butter, Whey protein, energy drinks, caffeine , soy food
Do you smoke/vape?* Yes No
Do you use fabric softener or dryer sheets?* Yes No
Do you swim in a chlorinated pool?* Yes No
What is your stress level right now?* Low Average Somewhat Stressed Very Stressed
How many hours of sleep do you get each night?*
Do you use a tanning bed?* Yes No
Anything else we need to know about your lifestyle, diet, medication, etc..
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