Face Reality New Client Questionnaire

Note: If the client is under 18 years of age, a parent or gaurdian can complete and sign this form on behalf of the client.
Client Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Address:*

Home Address

Street Address Line 2

CityState

Zip Code
Phone Number:*
Email:*
Emergency Contact Name:
Emergency Contact Phone:
How did you hear about us?
Medical History Questions
Please indicate if you have used any of the following medications (Select all that apply).*

Antibiotics (oral)Antibiotics (topical)AccutaneBenzoyl PeroxideRetin-A, Tazorac, DifferinThyroid medicationBlood thinning medicationsI do not use any of these medications
Please provide detail about the medications above, including when you last used them and how long you used them for.
Physician's name:*
Physician's phone number:
Please enter a valid phone number.
Are you currently under the care of a dermatologist?*

YesNo
Dermatologists's name:*
Dermatologist's phone number:
Please enter a valid phone number.
Do you have any of the following medical conditions? (select all that apply)*

Herpes SimplexHIV/AIDSHemophiliaEczemaThyroid ProblemsLupusPsoriasisHormone ProblemsAnemiaHepatitisHysterectomyHigh Blood PressureCancerOvary(ies) RemovedDiabetesStaph Infection/MRSAPacemakerMetal Pins in BodyI do not have any of these medical conditions
Lifestyle Questions
Have you ever had any reaction to any products or anything you have put on your face?*

YesNo
If yes, what products?*
Do you smoke cigarettes or vape?*

YesNo
If yes, what do you smoke?*
Are you allergic to any of the following?*

SulfurAspirinLatexI am not allergic to any of the above
Do you use fabric softener or fabric softener sheets in the dryer?*

YesNo
Do you swim in a chlorinated pool?*

YesNo
Do you work around chemicals, tars, oils, grease or inks?*

YesNo
Occupation*
Do you work work nights?*

YesNo
Are you currently under a lot of stress? (common stress triggers: job loss, new job, wedding, death in the family or close friend, graduation, long commute, heavily scheduled) *

YesNo
Do you use birth control pills, shots or use an IUD?*

YesNo
If yes, which do you use?*
If using birth control pills, please include the brand name.
Are you pregnant or nursing?*

YesNo
Do you have shaving irritation on your face?*

YesNo
What type of razor do you use for shaving?*
For example, double blade, triple blade, rotary
Dietary Questions
Do you consume any of the following? (select all that apply)

Fast FoodPeanutsProcessed FoodSushiSalty SnacksKelp and SeaweedMilk/YogurtMiso SoupCheeseSoyWhey or Soy ProteinVitamins/SupplementsPeanut ButterSeafoodI do not consume any listed
Have you ever used any Face Reality Skincare products?*

YesNo
If yes, please list the products:
Are you still using any of the Face Reality Skincare products above?*

YesNo
What other skincare products are you currently using?

CleanserTonerSerumsMoisturizersSunscreenMaskFoundationBlushExfoliant (acids, serums, scrubs)Acne MedicationsNoneOther
Please provide the brand names of the skincare products you are using.
What skincare treatments have you had in the past?

Chemical PeelsMicrodermabrasionDermabrasionLaser Hair RemovalLaser Rejuvenation/ResurfacingSkin Cancer RemovalFacial WaxingElectrolysisNoneOther
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment procedures.
Today's Date:*

MonthDayYear
Date
Your Signature:*

Clear
If the client is under 18 years of age, a parent or guardian may sign above.
Should be Empty:

Medical History Questions

Lifestyle Questions

Dietary Questions