Comprehensive Client Intake Form

Skin and Health Questionnaire

Please answer the following questions thoroughly and completely, as this provides a better understanding of your general health, lifestyle, and skin care concerns, thereby enabling the best skin care program to be customized for your individual needs.
Name*
Date of birth*
Address*
Occupation
Email*
example@example.com
Let us thank the person who referred you!
Skincare History
If there was something you could change or improve about your skin, what would it be?
What else? Please check all that apply:

Discoloration (Brown Spots or Melasma)Fine Lines & WrinklesDry, Flaky SkinOily SkinAcne/BreakoutsAcne ScarringEnlarged PoresRosaceaDilated CapillariesRedness (Reactive Skin)Uneven TextureSun DamageLoss of Facial ContoursLax or Sagging SkinDark Under-Eye CirclesHair Loss / Hair restoration
What is your primary skincare goal today?
On a scale of 1–5, how important is it for you to reach that goal?
What type of skin do you think you have?

DryNormalCombination
If oily, are you oily throughout the cheek area?

YesNo
Do you have a history of acne?*

YesNo
If yes, are you using or have you ever used any medications for acne?

YesNo
Name of medication:
Do you sunbathe or participate in outdoor activities?

YesNo
Have you ever had a reaction to any skincare product or cosmetic?

YesNo
If yes, please list it below.
What skincare do you currently use?

Prescription (RX): Examples: Tretinoin (Retin-A), Hydroquinone (4%), AczoneMedical Grade (Professional/ Clinical): Examples: SkinBetter Science, Alastin, ZO Skin Health, iS Clinical, Jan MariniDepartment Store (Luxury & Prestige): Examples: La Mer, Dior, Estée Lauder, Clé de Peau BeautéDrug Store (Mass Market): Examples: CeraVe, Neutrogena, Olay, AveenoIndie & Boutique Brands: Allies of Skin, Biophile, Dr. LorettaClean Beauty: Examples: Tata Harper, Ilia, BiossanceOrganic/Natural: Examples: Eminence Organic, True Botanicals, HerbivoreK-Beauty (Korean Skincare): Examples: Sulwhasoo, Laneige, COSRXJ-Beauty (Japanese Skincare): Examples: Tatcha, Shiseido, Hada LaboEuropean Pharmacy Brands: Examples: La Roche-Posay, Avène, BiodermaMinimalist & Fragrance-Free: Examples: Vanicream, The Ordinary, Paula’s ChoiceDIY & Homemade: Examples: Homemade honey masks, turmeric face masks
Morning

Please list your morning skincare routine.
1
2
2
3
4
5
Evening

Please list your morning skincare routine.
1
2
3
4
5
Please check if you are currently using or have ever used any of the following:

RetinolGlycolic AcidLactic AcidSalicylic AcidCitric AcidResorcinolBenzoyl Peroxide (BPO)HydroquinoneTretinoin (Retin A™, Renova™, Refisa™)Topical AntibioticsTopical SteroidsAdapalene (Differin™)Azelaic Acid (Azelex™, Finacea™)Isotretinoin (Accutane™)
Have you ever or are you currently receiving skin services?*

YesNo
Have you had any of the following?*

Chemical PeelsLaser ResurfacingFacial Cosmetic SurgeryFacial InjectiblesPermanent CosmeticsLight TreatmentsMicrodermabrasionDermaplaningExtractionsElectrolysisLaser Hair RemovalWaxingNone
General Health
Are you currently under the care of a physician?*

YesNo
If yes, please discuss contraindications of any pre-existing medical conditions with your physician.
Are you currently taking any medications?*

YesNo
If yes, please list here
Please check if you are allergic to any of the following:*

EggsSulfurAspirinNone
If you have any other known allergies, please list them
Please select the following conditions you have, or have had, in the service area

DermatitisEczemaPsoriasisOpen sores or lesionsCold sores/Fever blistersActinic KeratosisKeloid Scarring
Some treatments have contraindications to the following: Please check all that apply.

PacemakerHypersensitive (this would have been discussed by doctor)Implanted neurostimulatorAny electrical implanted device or implanted slow medication releaseEpilepsyActively receiving chemotherapy
If applicable, how long since last chemo or radiation treatment?

MonthDayYear
Date
Female Clients
Are you on hormone replacement therapy?*

YesNo
Are you currently taking birth control pills?*

YesNo
Are you pregnant or breastfeeding?*

YesNo
Is there anything else that should be known before starting your services?
Signature*

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Date*

MonthDayYear
Date

Skin and Health Questionnaire

Skincare History

Morning

Evening

General Health

Female Clients

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