Skin Intake Form
Full Name
First Name
Last Name
What is your age?
Contact Number
Format: (000) 000-0000.
Email Address
example@example.com
Are you currently under the care of a physician or dermatologist?
Yes
No
If yes, please explain:
Do you have any known skin conditions?
Acne
Eczema
Rosacea
Psoriasis
Hyperpigmentation
Other
Are you currently taking any medication (including oral contraceptives, acne medications, etc.)?
Yes
No
Please list them.
Do you have any allergies? (Including skin care products or ingredients)
Yes
No
Not Sure
Please list them.
Have you had any of the following treatments in the last 6 months?
Chemical Peel
Microdermabrasion
Botox/ Filler
Laser Treatment
Other
If you had any of the treatments listed above, how long ago was your treatment?
Do you have any autoimmune or chronic health conditions (e.g., diabetes, lupus, thyroid disorders)?
Yes
No
If yes, please specify:
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Skin Type & Concerns:
How would you describe your skin type?
Oily
Dry
Combination
Sensitive
Normal
Dehydrated
What is your main skin concern? (Check all that apply)
Acne
Wrinkles/Fine Lines
Uneven skin tone
Hyperpigmentation
Sensitivity/Redness
Dryness
Dullness
Large Pores
Other
Do you experience any of the following? (Check all that apply)
Frequent breakouts
Excessive dryness
Oily T-zone
Redness or irritation
Skin tightness
Flakiness
Sensitivity to products
None of the above
Current Skincare Routine:
What type of cleanser do you use?
Gel
Cream
Oil
Micellar Water
Other
Do you use exfoliants or scrubs?
Yes
No
If yes, what type and how often?
What type of moisturizer do you use?
Gel
Cream
Oil-based
Other
Do you use sunscreen regularly?
Yes
No
If yes, what SPF do you use?
Are you using any active ingredients (e.g., retinoids, acids, vitamin C)?
Yes
No
If yes, please list:
Lifestyle & Environmental Factors:
How often are you exposed to sun or UV rays?
Daily
Occasionally
Rarely
Never
Do you smoke or use tobacco products?
Yes
No
How would you rate your daily water intake?
Low
Moderate
High
Do you experience stress regularly?
Yes
No
Do you exercise regularly?
Yes
No
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