Client Intake Form

— § CLIENT INTAKE / VOL. 01 —

Form to collect detailed client information for skin care consultation and treatment planning.
Real time on the face.
Before we get started — a few things about your skin, your history, and your day-to-day. The more specific you are, the better the work.
— § 01 / IDENTITY —
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
How did you hear about SKIN FACTORY?
If referral or other, please list name
— § 02 / SKIN PROFILE —
How would you describe your skin most days?
Do you experience visible pores or congestion?
What are your top 2-3 skin concerns right now?
Do you currently have...
After washing your face, your skin feels...
When you apply moisturizer...
— § 03 / LIFESTYLE —
How much stress or sleep disruption do you experience?
How often are you outdoors?
Do you currently smoke, drink alcohol frequently, or have a high-stress work environment?
— § 04 / HOME ROUTINE —
Are you using any of the following at home?
Are you using any of the following at home?
Have You Ever Had a Facial or Skin Treatment Before?
How does your skin usually react to professional treatments?
If Yes, When?
— § 05 / TREATMENT HISTORY —
If Yes, What Type of Facial or Skin Treatment Did You Receive?
What Skin Care Products do you currently use?
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivatives?
Please specify which product or type, if you answered 'Yes, currently using' to above.
Have You Received Any of These Hair Removal Services On Your Face in the Last 30 Days?
Have You Ever Received Chemical Peels, Laser Services, or Microdermabrasion Treatments?
Have You Received any Botox, Juvederm, or Other Dermal Fillers in the Last Two Weeks?
— § 06 / MEDICAL —
Have You Experienced Any of These Health Conditions in the Past or Present?
If You Checked Yes to Any of These Please Provide Further Information.
Do You?
Any Known Allergies or Reactions From?
Any Known Allergies or Reactions From?
If Other Please Specify:
Have you Used or Been Prescribed Any Medications (Topical or Oral) for Acne / Acne Control?
If Yes, Please Specify What and Date Last Used
— § 07 / HORMONAL —
Have you Ever Experienced Claustrophobia?
Please Rate Your Stress Level
Are You Taking Birth Control?
Are You Pregnant or Trying to Become Pregnant?
— § 08 / SHAVING —
Any Menopause Issues?
Are You Undergoing Any Hormone Replacement Therapy?
What Is Your Current Shaving System?
Do You Experience Irritation From Shaving?
— § 01 / IDENTITY —
— § 02 / SKIN PROFILE —
— § 03 / LIFESTYLE —
— § 04 / HOME ROUTINE —
— § 05 / TREATMENT HISTORY —
— § 06 / MEDICAL —
— § 07 / HORMONAL —
— § 08 / SHAVING —
Come in. Leave better.
SKIN FACTORY · PASADENA · EST MMXX
Should be Empty:

— § CLIENT INTAKE / VOL. 01 —

Real time on the face.

Before we get started — a few things about your skin, your history, and your day-to-day. The more specific you are, the better the work.

— § 01 / IDENTITY —

— § 02 / SKIN PROFILE —

— § 03 / LIFESTYLE —

— § 04 / HOME ROUTINE —

— § 05 / TREATMENT HISTORY —

— § 06 / MEDICAL —

— § 07 / HORMONAL —

— § 08 / SHAVING —

— § 01 / IDENTITY —

— § 02 / SKIN PROFILE —

— § 03 / LIFESTYLE —

— § 04 / HOME ROUTINE —

— § 05 / TREATMENT HISTORY —

— § 06 / MEDICAL —

— § 07 / HORMONAL —

— § 08 / SHAVING —