Intake Form
Hi there 🖤 The purpose of this intake form is for me to understand your unique skin concerns, goals, and habits, as well as other factors that can contribute to your skin health. This information is extremely helpful to me as your esthetician because it allows me to give you a truly customized experience and understand where you need help. All information is confidential. If you have any questions feel free to reach out to me at (650)670-2334. Please complete before your appointment to avoid delays. See you soon and I'm super excited to help you feel more confident in your skin 🖤 Mariana
Personal Information
Name
*
First Name
Last Name
Email
*
example@example.com
Birth Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What is your occupation?
Preferred Pronouns
How did you hear about Glow & Dagger?
Medical Conditions
Do you currently have or have a history of any medical conditions? (Check all that apply)
*
Diabetes
Epilepsy or subject to seizures
Other autoimmune condition
Cancer treatment
Thyroid disorder
Pacemaker or other implanted device
PCOS/PMOS
Psoriasis
Rosacea
Eczema
None of the above
Other
Do you have any allergies? If yes, please list them below.
Are you currently pregnant, breastfeeding, or trying to conceive?
*
Yes
No
If pregnant, how far along are you?
First trimester
Second trimester
Third trimester
Medications
Are you currently taking or using any of the following medications?
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Accutane/Isotretinoin (current or within the past 6 months)
Antibiotics
Steroid creams
Blood thinners
Birth control
None of the above
Recent Treatments
Have you had any of the following facial treatments within the last 2 weeks? (Check all that apply)
*
Chemical peel
Waxing or threading (face)
Botox or fillers
IPL or Laser (face)
Microneedling
Excessive sun exposure/sunburn
None of the above
If yes, when did you receive the treatment?
Skin Goals + Concerns
What are your current skin concerns? (Check all that apply)
*
Acne/prone to breakouts
Clogged pores or blackheads
Hyperpigmentation
Dryness/flakiness
Sensitivity/redness
Fine lines/aging concerns
Uneven skin texture
Dehydration
Itchiness/tightness
Dark spots/post-acne marks
Dullness
Other
What's your biggest skincare struggle lately?
*
What do you want to get out of working with an esthetician?
Lifestyle + Skincare Habits
After cleansing, does your skin feel tight, dry or uncomfortable?
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Yes, every time I cleanse
Only sometimes
Never
How often do you need to moisturize for your skin to feel hydrated? (Check all that apply)
*
Never or only occasionally
Once a day
Twice a day
Multiple times a day
How would you describe your skin’s oil production?
*
My facial skin is rough or dry.
My facial skin is oily in some areas.
My face is very oily.
My face is neither oily nor dry
Have you experienced any of the following in the past 4 weeks? (Check all that apply)
*
Acne/clogged pores
Facial redness or flushing
Stinging or burning
Allergic reactions such as a rash or redness
Irritation from shaving the face
None of the above
Would you consider your skin to be sensitive?
*
Yes
No
Which products do you currently use regularly in your AM routine?
*
Cleanser
Toner
Serum
Moisturizer
Eye cream
SPF
Nothing consistently
Which products do you currently use regularly in your PM routine?
*
Cleanser
Toner
Serum
Moisturizer
Eye cream
Nothing consistently
How consistently do you follow your skincare routine?
*
Every day
Most days
A few times a week
Rarely
Do you use a retinoid (retinol, retinal, tretinoin, adapalene, etc.)? If yes, how often?
*
1x/week
2-3x/week
4x or more/week
A couple times a month
I do not use any retinoids
Do you exfoliate your skin (scrubs, glycolic acid, salicylic acid, fruit enzymes) If yes, how often?
*
1x/week
2-3x/week
4x or more/week
A couple times a month
I do not exfoliate
How often do you wear SPF?
*
Daily
Sometimes
Rarely
Never
Select all statements that apply to you based on your lifestyle habits
*
I have smoked over 50 cigarettes or cigars in my life
I am exposed to second hand smoke on a weekly basis.
I currently smoke or vape nicotine or cannabis products.
I often get less than 7 hours of sleep a night.
I feel stressed at least 2 hours a day.
Are you exposed to pollution or bad air quality more than 3 times a week?
I eat sugary foods over 3 times a week.
I do not eat fruit or vegetables every day.
None of the above
Select all statements that apply to you based on your suncare habits
*
I have been to a tanning bed more than 3 times in my life.
I am exposed to the sun for over 3 hours a week.
I spend over 3 hours a week close to a window during daylight hours (including driving).
My face has been sunburned and peeled more than twice in my life.
I do not wear sunscreen every day
I do not wear sunscreen during outdoor activities
None of the above
Please take this quick 3 minute quiz to determine your skin type
(click here to take quiz)
. Please enter your results below.
*
Additional Information
Is there anything you'd like me to avoid during your treatment? (E.g., strong scents, certain massage areas, bed heating, music, etc)
Is there anything else you'd like me to know?
By signing below, I acknowledge that the information I have provided is accurate and complete to the best of my knowledge. I understand that failure to disclose relevant medical or skincare information may result in adverse reactions for which Glow & Dagger Skincare cannot be held responsible.
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