Client Questionnaire
Facial Treatment
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What is your usual skin type?
Dry
Normal
Combination
Oily
Sensitive
Please indicate if you have used any of the medications or drugs listed below in the last 2 years, when they were used, and for how long you used them: Antibiotics (oral), Antibiotics (topical), Accutane, Benzoyl Peroxide, Retin-A, Tazorac, Differin, Thyroid medication, Blood Thinning Meds.
MEDICAL HISTORY (PLEASE CHECK ALL THAT APPLY)
Herpes Simplex
HIV/AIDS
Hemophilia
Eczema
Thyroid Problems
Lupus
Psoriasis
Hormone Issues
Anemia
Hepatitis
Hysterectomy
High Blood Pressue
Cancer
Removed Ovaries
Diabetes
Staph Infection/MRSA
Pacemaker
Metal Pins in Body
Are you under a dermatologist’s or other physician’s care?
Yes
No
If yes, doctors name:
Are you taking any medications? If so, Please list them below.
Have you ever had any reaction to any products or anything you have put on your face?
Yes
No
If yes, what products?
Please check any of these you are allergic to:
Sulfur
Aspirin
Latex
List any other allergies:
Do you smoke/vape?
Yes
No
Do you drink energy drinks/caffeinated beverages?
Yes
No
Rate your stress level on a scale of 1-10
Do you use birth control pills, shots or use an IUD?
Yes
No
Are you pregnant or nursing?
Yes
No
How many oz. of water do you consume daily?
How many hours of sleep do you get per night?
PRODUCTS CURRENTLY USING - Please provide product names
What else have you done for your skin in the last 90 days? Chemical Peels? If so, what kind? Microdermabrasion? Dermabrasion? Laser Hair Removal? Laser Rejuvenation/Resurfacing? Skin Cancer Removal? Facial Waxing? Electrolysis? Please list any treatments below:
I consent to photos/videos being taken during my appointment for marketing, educational, and promotional purposes
Yes
No
By submitting this form, I confirm that the information provided is accurate and I consent to receiving facial services as booked.
Continue
Continue
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