Intake Form

Intake Form
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Allergies to food or drugs
Occupation
Do you work
Are you currently pregnant or breastfeeding?
Are you currently under the care of a physician, dermatologist, or other medical provider for your skin?
if yes explain:
Do you have any diagnosed skin conditions?
What is bothering you MOST about your skin right now?
How long have you been experiencing this concern?
- Less than 1 month
- 1–3 months
- 3–6 months
- 6–12 months
- Over 1 year
1. Has it gotten:
- Better
- Worse
- Stayed the same
- Fluctuates
1. What do you want your skin to look and feel like in the next 8–12 weeks?
How does your skin usually feel a few hours after cleansing (without applying products)?
By midday, your skin is usually:
How often do you experience flaking or peeling?
How often do you feel oily or greasy?
How visible are your pores?
Which best describes your skin?
Do any of the following happen when you apply skincare products? Select all that apply
Does your skin feel “stripped” after washing?
Does your skin ever feel both oily AND dehydrated/tight?
Does your skin become irritated easily with new products?
Have you ever damaged your skin barrier from overuse of products?
Do you currently have any of the following:
How would you describe your skin sensitivity?
Do you experience redness easily after:(Check all that apply)
What are your top 3 skin concerns?(Check all that apply and rank top 3)
Do you currently break out?
What type of breakouts do you get most often?
Where do you break out most often?
How often do you experience breakouts?
Do your breakouts worsen around your menstrual cycle?
Do you pick, squeeze, or pop blemishes?
Do your breakouts leave:
Do you struggle with discoloration or uneven tone?
What type of discoloration do you notice?
When did discoloration begin?
Does your skin tan or hyperpigment easily after inflammation or irritation?
Have you ever been diagnosed with melasma?
Are you concerned about signs of aging?
What concerns apply?
Which areas concern you most?
How would you describe your skin texture?
Do you have allergies or sensitivities to any skincare ingredients or products?
If yes, list them
Have you ever reacted badly to:(Check all that apply)
Have you ever used prescription skincare?
If yes, are you currently using any prescription skin medications?
if yes, list them and frequency
Morning Routine
1. What cleanser do you currently use in the morning?
2. What toner/essence do you use?
3. What serums or treatments do you use?
4. What moisturizer do you use?
5. What SPF do you use?
6. Do you reapply SPF?
Evening Routine
1. What cleanser do you use at night?
2. Do you double cleanse?
- Yes
- No
1. What treatments/serums do you use at night?
2. What moisturizer/night cream do you use?
3. Do you use eye cream, spot treatments, or facial oils?
- Yes
- No
- If yes, list them.
How often do you exfoliate?
What exfoliants do you use?
Have you ever “skin cycled” or rotated active ingredients?
Do you feel your current routine is:
How much water do you drink daily?
How would you describe your stress levels?
How many hours of sleep do you get on average?
Do you smoke or vape?
Do you frequently consume:(Check all that apply)
Do you notice skin flare-ups from:
How often do you wash makeup brushes/sponges?
Do you sleep in makeup?
How often do you change pillowcases?
How often are you in the sun?
Do you wear sunscreen daily?
Have you had significant sun exposure or tanning in the past?
Do you currently use tanning beds or intentionally tan?
Does your skin:
Do you believe hormones impact your skin?
Have you experienced any of the following recently?(Check all that apply)
Have you had any professional skin treatments in the last 6 months?(Check all that apply)
Workout/ Strenuous Activity
Are you interested in eventually receiving professional treatments in addition to homecare?
How many skincare steps are you realistically willing to do?
Monthly Skincare Budget
Are you open to:
Photo uploads

Photo Instructions: Please upload clear, makeup-free photos in natural lighting. No filters, no makeup, no heavy moisturizer or oils. Pull hair away from face.
Photo upload

Front face photo
Cancelof
File Upload

Left side profile
Cancelof
File Upload

Right side profile
Cancelof
File Upload

Forehead close-up
Cancelof
File Upload

Cheeks close-up
Cancelof
File Upload

Chin/ jawline close-up
Cancelof
Drivers License

Cancelof
What products have worked well for you in the past?
What products or treatments did not work for you?
Are there any ingredients or products you do not want to use?
Anything else you want me to know about your skin?
Final acknowledgement:
Signature
Date

MonthDayYear
Date
Thank You

Thank you for completing your JessBeauty Esthetics Virtual Skin Analysis Form. Your intake and photos will be reviewed, and your customized homecare recommendations will be created based on your skin concerns, skin history, lifestyle, product use, and submitted images. Please monitor your email or text messages for your personalized skincare plan.

Intake Form

Photo uploads

Thank You