New Client Evaluation Form

DAMION JENKINS, MSN, RN

Registered Nurse with over 15 years experience
RN Mobile Skincare

SKIN CARE EVALUATION
Instructions:

Please complete this new client evaluation form before your appointment can be scheduled and services are rendered. This will provide Damion with the required information to make effective and safe decisions regarding treatment options to best meet your skincare needs. All information contained in this form will be securely maintained, upholding client confidentiality practices. Information in this form will only be used for treatment services, consultation and ongoing skincare management. *Clients only have to complete this intake form once - UNLESS there have been changes to the health history. Please advise Damion of any changes as they occur.
Personal Information
Full Name*

First NameLast Name
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Cell Phone*

Area CodePhone Number
E-mail*
What Treatments or Services are you Interested in?*

General Skin Health & Wellness ConsultingMicrodermabrasion or DermaplaningMicroneedling with Serum InfusionTreatment of Minor Skin IrregularitiesOther
What is your skin complexion?*

LightMediumOliveDark
What skin type do you have?

DryOilyCombination
Do you have any of the following minor skin imperfections that you would like treated?

Skin TagsCherry Angiomas (ruby points)Broken CapillariesKeratosis (barnacles)Sebaceous HyperplasiaMiliaSun SpotsAcneBlackheadsLarge PoresFine Lines & WrinklesNONE OF THESE
What do you want to improve most about your skin?
Please complete the following health-related questions:
Do you have any allergies?*

YesNo
If you do have allergies, what are they?
Have you seen a Dermatologist in the past year?*

YesNoI don't have a dermatologist and need a referral
Reason for visit
Have you had any cosmetic or health-related skin surgeries*

YesNo
If so, when?
If so, what type of surgery and where?
Please describe any adverse reactions from skin care products, cosmetic or skin care treatments experienced within the past 12 months - if none, type N/A.
Are you taking any of the following medications? Select all that apply:*

AccutaneWarfarin (Coumadin)Enoxaparin (Lovenox)HeparinAspirin 325mgIbuprofen (Advil, Motrin)Dabigatran (Pradaxa)Rivaroxaban (Xarelto)Apixaban (Eliquis)Fondaparinux (Arixtra)Edoxaban (Savaysa)Dalteparin (Fragmin)Danaparoid (Orgaran)Clopidogrel (Plavix)Prasugrel (Effient)Ticagrelor (Brilinta)Dipyridamole (Persantin)PrednisoneMethylprednisoloneAdalimumabInfliximabEtanerceptCosentyx (Secukinumab)Stelara (Ustekinumab)Humira (Adalimumab)Tremfya (Guselkumab)InsulinDiabetic Oral MedicationsNONE OF THESE
Do you use any of the following routine skincare products?
Cleanser*

YesNo
Cleanser Brand, Type, How Often?
Moisture Balance*

YesNo
Moisture Brand, Type, How Often?
Serums*

YesNo
Serum Brand, Type, How Often?
Face Oil*

YesNo
Face Oil Brand, Type, How Often?
SPF*

YesNo
SPF Brand, Type, How Often?
Exfoliation or Mask Treatment (1-2x per week)*

YesNo
Exfoliation or Mask Treatment Brand, Type, How Often?
best
Do you have any of the following health conditions: Select all that apply:
AcneCold Sores (Herpes Simplex)EczemaEye Infection or StyesPsoriasisSkin CancerWartsMolesFungal InfectionsShingles (Herpes Zoster)Cracked, Fissured or Painful Dry SkinScarsRosaceaContact DermatitisSensitive or Hyperreactive SkinAllergic Reactions (Hives)SunburnRashesWounds or Open Skin areasNONE OF THESE
Are you considered to be immunocompromised? (AIDS, Cancer, on Immunosuppressive Treatment for Organ Transplant, or Autoimmune Diseases?)*

YesNo
Are You Pregnant?*

YesNo
Are You Breast Feeding?*

YesNo
Any Other Conditions or Concerns to note?
Do you smoke*

YesNo
How much?
How long?
Are you light sensitive (eyes or skin)?*
The next questions are related to tanning and/or sunbathing:
When did you last sunbathe?
Do you use artificial tanning cream?
When did you last use a tanning booth?
When was the last time you were in direct sunlight for more than 1-hour?
Have you recently vacationed or are you planning a vacation with sun exposure?*

YesNo
If so, when?
If Yes, when? If No, type N/A
Check the number that best describes your skin's response to sun exposure without SPF protection?*

Fitzpatrick I Always burn, never tanFitzpatrick II Always burn, sometimes tansFitzpatrick III Sometimes burn, always tansFitzpatrick IV Always tan, rarely burnFitzpatrick V Light Brown to Medium Dark skin, rarely burnFitzpatrickVI Dark Brown to Black skin, never burn
How did you hear about this service and/or the procedure that you're interested in?
Thank You for Completing this New Client Intake Form!

All information contained in this form is securely stored and will remain confidential. Please look out for a follow-up email with a link to SCHEDULE Your Treatment and/or Service. If you have questions, please contact Damion via the website: www.rnmobileskincare.com - under "After Care Instructions" then "Contact Damion with Any Concerns".
*All clients will need to sign a consent to treatment form as well as a social media consent form upon booking services.

Thank you! I look forward to providing you with excellent care!
Should be Empty:

DAMION JENKINS, MSN, RN

RN Mobile Skincare

Instructions:

Do you have any of the following health conditions: Select all that apply:

Thank You for Completing this New Client Intake Form!

*All clients will need to sign a consent to treatment form as well as a social media consent form upon booking services.