Client Questionnaire

Client Questionnaire
YOUR INFORMATION
Name
Address
Age
DOB
Ethnicity
City
Zip
Email
example@example.com
Cell Phone
Other Phone
Please indicate if you have used any of the medications or drugs listed below in the last 2 years, when they were used.

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:
Oral AntibioticsTopical AntibioticsAccutaneBenzoyl PeroxideRetin-A, Tazorac, DifferinThyroid MedicationBlood Thinning MedicationOther
MEDICAL HISTORY (PLEASE CHECK ALL THAT APPLY)
Herpes SimplexHIV/AIDSHemophiliaHepatitisStaph Infection/MRSAEczemaPsoriasisCancerThyroid ProblemsHormone ProblemsHysterectomyOophorectomyPacemakerLupusAnemiaHigh Blood PressureDiabetesMetal Pins In Body
YOUR PRIMARY CARE PHYSICIAN:
Name
Phone
YESNO
If yes doctors name
LIFESTYLE CONSIDERATIONS
YESNO
If yes what products
SULFURASPIRINLATEX
List any other allergies you know of
YESNO
If yes what do you smoke
YESNO
YESNO
YESNO
Occupation
YESNO
PILLSHOTIUD
What brand of pill
YESNO
YESNO
If yes, what type of razor do you use for shaving? (I.E double blood, triple blade, rotary)
DIET - DO YOU CONSUME THE FOLLOWING?
FAST FOODPROCESSED FOODSALTY SNACKSMILK/YOGURTCHEESEWHEY OR SOY PROTEINPEANUT BUTTERPEANUTSSUSHIKELP AND SEAWEEDMISO SOUPSOYVITAMINS/SUPPLEMENTSSEAFOOD
Have you ever used Face Reality Skincare products? If yes, please list products:
YESNO
PRODUCTS CURRENTLY USING - PLEASE PROVIDE PRODUCT NAMES
CLEANSER
SUNSCREEN
MOISTURIZERS
SERUMS
TONER
MASK
FOUNDATION
ACNE MEDICATIONS
EXFOLIANT ACIDS SERUMS SCRUBS
BLUSH
ANYTHING ELSE
OTHER TREATMENTS: WHAT ELSE HAVE YOU DONE FOR YOUR SKIN IN THE LAST 90 DAYS?
CHEMICAL PEELSMICRODERMABRASIONDERMABRASIONLASER HAIR REMOVALLASER REJUVENATION/RESURFACINGSKIN CANCER REMOVALFACIAL WAXINGELECTROLYSISOther
How did you hear about us
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Client Questionnaire

YOUR INFORMATION

MEDICAL HISTORY (PLEASE CHECK ALL THAT APPLY)

YOUR PRIMARY CARE PHYSICIAN:

LIFESTYLE CONSIDERATIONS

DIET - DO YOU CONSUME THE FOLLOWING?

PRODUCTS CURRENTLY USING - PLEASE PROVIDE PRODUCT NAMES

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