Malaya Skin+Face Client Questionnaire

Malaya Skin+Face

Client Questionnaire: All information provided in this form is strictly confidential and will be used solely for the purpose of providing professional skincare services. Your personal and medical details will not be shared with any third parties without your explicit written consent, except as required by law. If you wish to authorize the release of any information, please provide written permission.
Name

First NameLast Name
Date of Birth

Please indicate if you have used any of the medications or drugs listed below in the last 2 years, when they were used, and for how long you used them.

Rows	Medication	When	How Long
Antibiotics (oral)
Antibiotics (topical)
Accutane
Benzoyl Peroxide
Retin-A, Tazorac, Differin
Thyroid medication
Blood Thinning Meds

Please list any other medications or drugs listed that you have used in the past 2 years and include when they were used, and for how long you used them:
MEDICAL HISTORY (PLEASE CHECK ALL THAT APPLY)
LIFESTYLE CONSIDERATIONS
Have you ever had any reaction to any products or anything you have put on your face?
If yes, what products?
Please check any of these you are allergic to
List any other allergies you know of:
Do you smoke/vape?
If yes, what do you smoke?
Do you use fabric softener or fabric softener sheets in the dryer?
Do you swim in a chlorinated pool?
Do you work around chemicals, tars, oils, grease or inks?
Occupation:
Do you work nights?
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)

Do you use birth control pills, shots or use an IUD?
If so, which do you use? What brand of pill?
Are you pregnant or nursing?
Do you have shaving irritation on your face?
Type a What type of razor do you use for shaving (i.e, double blade, triple blade, rotary)

DIET - DO YOU CONSUME THE FOLLOWING?

Rows	How Often a Week
Fast Food
Processed Food
Salty Snacks
Milk/Yogurt
Cheese
Whey or Soy Protein
Peanut Butter
Peanuts
Sushi
Kelp and Seaweed
Miso Soup
Soy
Vitamins/ Supplements
Seafood

PRODUCTS CURRENTLY USING - PLEASE PROVIDE PRODUCT NAMES

Rows	Product Name
CLEANSER
TONER
SERUMS
MOISTURIZERS
SUNSCREEN
MASK
FOUNDATION
BLUSH
EXFOLIANT (ACIDS, SERUMS, SCRUBS)
ACNE MEDICATIONS
ANYTHING ELSE?

OTHER TREATMENTS: WHAT ELSE HAVE YOU DONE FOR YOUR SKIN IN THE LAST 90 DAYS?

Rows	When	Where
Chemical Peels
If so, what kind:
Microdermabrasion
Dermabrasion
Laser Hair Removal
Laser Rejuvenation/Resurfacing
Skin Cancer Removal
Facial Waxing
Electrolysis
Other

How did you hear about us?
For Clients Under 18:

If the client is under the age of 18, a parent or legal guardian must provide consent before any service is performed. A parent or guardian must either: (1) be present during the session, or (2) sign below to authorize the service.
Parental/Guardian Consent:
I, [Parent/Guardian Name], as the parent/legal guardian of First Name Last Name , give my consent for them to receive skincare services. I understand and acknowledge the nature of the service and agree to the terms outlined above.
Signature
Date
Should be Empty:

Malaya Skin+Face

LIFESTYLE CONSIDERATIONS

For Clients Under 18:

Parental/Guardian Consent: