Does your job require that you work outdoors?NoYes

1) Have you ever had a facial treatment before? NoYes, when?

2) Have you ever had a body spa treatment before? Massage: No Yes Salt glow: No Yes Seaweed wrap: No Yes Mud: No Yes Body scrub: No Yes Other:

3) Which of the following best describes your skin type? (Please circle one type number) I. Creamy complexion Always burns easily, never tans II. Light Complexion Always burns, tans slightly III. Light/Matte Complexion Burns moderately, tans gradually IV. Matte Complexion Seldom burns, always tans well V. Brown Complexion Rarely burns, deep tan VI. Black Complexion Never burns, deeply pigmented

4) Do you have any special skin problems or concerns pertaining to your face or body? Yes No

5) Have you ever had chemical peels, laser or microdermabrasion? m No m Yes In the last month? No Yes 6) Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products? No Yes

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7) Have you used any of these products in the last 3 months? No Yes

8) Have you used an acne medication? No Yes, when?

9) What skin care products are you currently using? (List brand where known) 10) Have you recently used any self-tanning lotions, creams or treatments? No Yes, specify: 11) Have you used any of the following hair removal methods in the past six weeks? No Yes, circle all that apply.

Shaving Waxing Electrolysis Plucking Tweezing Stringing Depilatories 12) What areas of concern do you have regarding your: Skin: (Please check any that apply and explain) Breakouts/acne Uneven skin tone Blackheads/whiteheads Sun damage Excessive oil/shine Wrinkles/fine lines Rosacea Dull/dry skin Broken capillaries Flaky skin Redness/ruddiness Dehydrated Sun spot/liver spot/brown spot Other

Eyes: Dehydrated Wrinkles Puffiness Dark Circles. Other: Lips: Dehydrated Cracked/chapped lips Other: 13) Have you ever had an allergic reaction to any of the following? (Please check any that apply and

explain) If yes, please explain:

Medicine Fragrance Food Shellfish Animals Latex Sunscreens Drugs lodine Pollen Other

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15) What SPF do you use on your body?

16) Have you had any recent tanning bed or sun exposure that changed the color of your skin? m

17) Have you experienced Botox, Restylane or Collagen injections? m No m Yes

Female Clients Only: 18) Are you taking oral contraceptives? No Yes specify:

19) Any recent changes to or from your contraceptive treatment? No Yes

20) Are you pregnant or trying to become pregnant? No Yes 21) Are you lactating? No Yes 22) Any menopause problems? No Yes

23) Are you undergoing any hormone replacement therapy? No Yes

Male Clients Only: 24) What is your current shaving system? Wet shave 25) Do you experience irritation from shaving? No Yes Ingrown hairs? No Yes Please use this space to complete answers where space was insufficient. (Please include the

Future Appointments/Contact: May I call you at your home, work or cell phone number to confirm future appointments? No Yes May I contact you via mail/email about future promotions and news? No Yes

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previ- ous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or skin care profes- sional from liability and assume full responsibility thereof.

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