Promised Skincare™ Intake Form
Custom Tailored Skincare Protocol
Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Date
Gender
Female
Male
Email
*
example@example.com
Phone Number
*
Skin Condition Intake
Please fill out below:
Check all symptoms that apply
*
Eczema (Atopic Dermatitis)
Seborrheic Dermatitis
Acne (Cystic, Hormonal, or Chronic)
Psoriasis
Rosacea
Fungal skin infections (e.g., Tinea, Candida)
Contact Dermatitis (Allergic or Irritant)
Perioral Dermatitis
Keratosis Pilaris (Bumpy skin)
Hyperpigmentation or Melasma
Redness, blotchiness, or flushing
Chronic dryness or flakiness
Oily skin or excessive sebum
Frequent breakouts (non-acne)
Hives or welts
Itching without visible rash
Skin sensitivity or reactivity
Burning or stinging sensations
Delayed healing of wounds or breakouts
Skin thickening or texture changes
Cracking around mouth, eyes, or joints
Dandruff or scalp irritation
Discoloration or uneven tone
Skin worsens with stress or emotional upset
Diagnosed autoimmune skin condition
Diagnosed hormonal imbalance impacting skin
Other (please describe in intake form)
Other
If selected "Other" please explain:
What skin conditions are you experiencing?
How long have you had this condtion?
Lifestyle and Stress
Please fill out below:
How would you rate your daily stress levels (1-10 scale):
How many hours do you sleep per night?
Any major emotional trauma? Please explain:
How would you describe your diet?
Do you currently follow a skincare routine? If yes, describe your routine:
Average # of workouts per week?
Medical Background
Informational only:
Are you under a doctor's care for skin issues?
Yes
No
List any current medications or topical treatments
Legal Checkboxes:
*
I understand this service is not medical advice or treatment
*
I agree to the Terms of Service and Informed Consent Agreement
*
I consent to the collection of my information according to the Privacy Policy.
30-minute Consultation Appointment
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