SKIN HEALTH QUESTIONNAIRE
Professional Treatment Consent Form
Client should complete the following, as directed, as thoroughly and in as much detail as possible.
Name
First Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Daytime Phone
Format: (000) 000-0000.
Evening Phone
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Birthdate
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Emergency Contact
First Name
Last Name
Relation to Contact
Your Physician
First Name
Last Name
Phone Number
Format: (000) 000-0000.
How did you hear about us?
Occupation
Interest
Please indicate which services you are interested in:
Skincare Consultation/Advice
Clinical Treatments
Acne Treatment/Management
Home Care Products
Age Management
Rosacea
What do you wish to change about your skin?
Medical History
Are you currently, or have you previously experienced any of the following:
Heart condition
Cancer
Hemophilia
Herpes Simplex
Pacemaker
Thyroid condition
Asthma
AIDS/HIV Positive
Headaches
Kidney problems
Diabetes
Anemia
High blood pressure
Hypo/Hyper glycemia
Low blood pressure
Arthritis
Hepatitis
Contact Lenses
Other
If you are currently experiencing or being treated for any health-related condition, please describe:
Have you ever had surgical or non surgical procedure? If yes, where on your body was the surgery performed?
Do you have any allergies? Also list any skin treatment products you have used that caused an unexpected reaction or side-effect:
Please list all over-the-counter and prescription medications you are currently taking:
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Please indicate if you have ever used any of the following medications for skin treatment:
Medications for skin treatment
Accutane
Cortisone
Staticin
Benzoyl Peroxide
Retin A
Sulfer
DesquamX
Zerac
Fosdex
Glycolic Acid
Salicylic Acid
Lactic Acid
Renova
Clindamycin
Tazoratene
Metrogel
What condition were you treating with this medication(s)?
When was the last time you used these medications?
Women
Are you pregnant?
Yes
No
Are you planning a pregnancy in the near future?
Yes
No
Are you currently on any type of hormone therapy? If yes please describe:
Do you have regular periods?
Yes
No
Are you going through menopause?
Yes
No
Do you have any hormone imbalance?
Yes
No
Have you undergone surgical menopause (hysterectomy)
Yes
When?
Skin Self-Analysis
What skincare products are you currently using?
Are you wearing a daily sunscreen?
SPF:
Is your skin:
Oily or acne prone?
Dry?
Normal?
Sensitive?
Have you ever treated or been treated for a skin condition? If yes, what condition?
How did you treat the condition:
Dermatologist
Aesthetician
Drug Store
Department Store
Were you happy with the result?
Yes
No
Are you currently treating or being treated for any skin condition?
Lifestyle and Stress Analysis
Do you come in contact with any chemicals at work?
Do you work around excessive heat or cold?
Do you use Personal Protective Equipment (PPE*)? If so, what type and for how long? *Masks, gloves, shields, etc.
How often do you exercise?
Average hours of sleep?
What is your stress level?
How many minutes a day are you exposed to sunlight?
How many hours a week do you use a tanning bed?
Do you get cold sores?
Father
Mother
Please indicate any of the following that apply to your eating habits:
Fast food
Baked Bread
Salt your food
Seafood
Dairy products
Ethnic or Spicy foods
Peanut Butter
Peanuts
How much water do you drink per day?
Caffeine?
Carbonated drinks?
Do you smoke tobacco products?
Average alcohol consumption per week?
Have you changed your brand of skincare products in the last year? If yes, why did you change?
I understand and agree that I am ultimately responsible for payment in full for services recieved.
Signature of Patient or Responsible Party:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship to Patient:
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