CIRCADIA

Advanced Professional Skincare

CONFIDENTIAL SKIN HEALTH QUESTIONNAIRE

EXPECTATIONS and HISTORY 3. Which conditions would you like to improve? Acne scarring

Hyperpigmentation Broken capillaries

4. Have you ever had facial treatment in the past?

6. How would you describe your skin? Oily Dry 7. How would you rate your skin? (Circle one)

I Always burns, never tans Il Always burns easily, tans slightly III Burns moderately - tans gradually IV Seldom burn - Always tans well V Rarely burns - Deep tan VI Never burns - Deeply pigmented

Circadia by Dr. Pugliese, Inc.

Tightness? Excessive oily shine during day?

9. What is your present skin regimen? Soap & water only

10. Are you ever exposed to chemicals, oils, or other caustic substances that may aggravate your skin?

11. Do you blush easily? If yes, what are the contributing factors?

14. Are you under treatment for any current skin condition?

15. Does your skin heal 16. Do you bruise easily? 17. Do you get sores/blisters (Herpes Zoster/Shingles)?

19. Have you ever used Topical Antibiotics

20. Any personal or family history of skin cancer?Yes

21. How would you describe your overall health?

22. Have you had any of the following, past or present?

Acne Allergies Arthritis or Bursitis Blood Pressure Breast Implant Cancer Cataracts Cholesterol Claustrophobic Diabetes

Yes Yes Yes High Yes Yes Yes High Yes Yes

Circadia by Dr. Pugliese, Inc.

Diarrhea/constipation Eczema Epilepsy Hay Fever Headaches Heart Disease/Conditions Hepatitis

Infections Lupus Menopausal Metal Implants Pace Maker Phlebitis Serious Injury Sleep problems Thyroid Varicose Veins

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

No No How often No What No No No No No No No No No What No

Do you smoke? Do you wear contact lenses? 23. Have you ever had a reaction to Fragrance 24. FOR WOMEN: Oral contraceptives? Are you pregnant or trying to get pregnant? Are you taking hormone replacement? Do you experience hormone imbalances? 25. FOR MEN: Do you shave with Do you experience skin breakouts? Do you have ingrown hair?

Yes Yes Yes Yes Electric shaver? Yes Yes

1. Is your stress level 2. Do you normally sleep well? 3. Do you regularly exercise? 4.Do you have food intolerances? 5. Do you follow any special diet? 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 facial treatments or physician referral in order to achieve your skin improvement goals.

,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 necessary. I also am aware that individual results are dependent upon my age, skin condition, and lifestyle. I agree to actively participate in following appointment schedules and home care procedures to the best of my ability, 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, I 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 after your appointment SO that the situation may be corrected. It is our policy to provide you with the best professional service and products customized for your skin condition.

I have read and understood all of the foregoing information

Circadia by Dr. Pugliese, Inc.