Confidential Skincare Intake Form

Confidential Skincare Intake
Welcome! Please complete this Intake to the best of your ability both prior to your first Spa Aeon session and any time your health information has changed.

This is a detailed Health Intake with many sensitive but important questions, so please fill it out privately, fully, and at a time when you have all of your skincare products, medications, and supplements at hand, and be sure to keep scrolling until you have answered everything, signed, and clicked Submit.

Professional Estheticians make many judgement calls during the course of treatment. We are trained to customize office and home treatment plans to maximize the health and beauty of your largest organ - the skin! Having an up-to-date health history enables us to make the safest, best choices as we treat your skin, so that you may enjoy the benefit of our full range of knowledge. The health and lifestyle topics addressed herein ALL have the potential for affecting your skin or causing interactions with aspects of your treatment at Spa Aeon... if they didn't, they would not be included.

As such, please note the following: if you are not sure or would prefer to discuss a matter in person with your Esthetician, for your safety, please indicate this in your response so that we will be alerted of the need to address your special concern! Keep in mind that incorrect or incomplete health records can lead to adverse skin reactions even with the most capable Esthetician.

Your Health Intake and Treatment Notes are held in the strictest confidence.

You may complete this Intake as many times as you need, especially if your health condition is in flux.
Full Name*

First NameLast Name
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Birthday

MonthDayYear
Referred by*
Are you seeking

In Person Professional Skin TreatmentDistance Evaluation for Home Skincare
Will this be your first time under the care of an Esthetician?

YesNoOther
What skin concern has been the most pressing for you in the past 30 days?
Please select all of the following that apply to your skin:

Rough TextureDull SkinClogged PoresBumpsAcne BreakoutsAcne ScarsDry SkinFine LinesWrinklesBrown SpotsHyperpigmentationRednessBlotchy SkinSensitive SkinSkin ReactionsBroken CapillariesCold SoresItching/BurningOther
What ongoing results would you like to see?
Selfie Time! Please add a clear, well-lit, makeup-free selfie for skin assessment:

What skincare products and topical prescriptions are you currently using at home? Be sure to include EVERYTHING that you apply to your skin.

	Brand	Product Name	Purpose	Mornings, Evenings, or Both?	How many times per week?
Cleanser
Toner
Serum
Blemish Control
Rx Cream
Mask
Exfoliant
Moisturizer
Lotion
SPF
Makeup
Other
Other
Other

Topical Retinoids are a category of anti-aging & anti-acne prescription and non-prescription skincare products that use a variety of different molecular forms of Vitamin A to treat the skin. Retinoids may include: Retin-A, Renova, Tretinoin, Differin, Green Cream, Tazorac, Retinol, Retinyl Propionate, Vitamin A, or Beta Carotene.

Topical Retinoid treatment may make up an important part of your Spa Aeon treatment plan. It is also important for safe treatment selection that we know beforehand if you are already using them.
Do you use Topical Retinoids?

YesNoNot SureOther
If so, which one and how often?
Certain other topical ingredients are considered highly active and may impact the best choice of treatment and treatment timing for you at Spa Aeon. You may have already covered these above, but just to be sure, are you currently using any of the following on your skin, even occasionally:

Topical Vitamin CAlpha Hydroxy Acids (may be listed as Glycolic Acid or AHA)Beta Hydroxy Acid (also known as Salicylic Acid or BHA)Hydroquinone (a skin lightening agent)Topical Antibiotics for acneHydrocortisone or other steroid creamsBenzoyl Peroxide

What oral medications, supplements, and other substances are you currently using? Be sure to include EVERYTHING that goes into your body, and don't forget common medications like birth control, antibiotics, sleep aids, energy drinks/supplements, and antiviral medications.

	Brand	Product Name	Purpose	Mornings, Evenings, or Both?	How many times per week?
Medication
Medication
Medication
Medication
Medication
Supplement
Supplement
Supplement
Supplement
Supplement
Alcohol
Caffeine
Energy Drinks
Nicotine
Marijuana/THC
Other
Other
Other

Have you used the Prescription Oral Acne Medication ACCUTANE or any other brand of Prescription Oral ISOTRETINOIN in the past 6 months?

YesNot SureNoOther
Do you have any allergies?
Do you wear contact lenses?

Yes, alwaysNo, neverSometimes
What is your occupation?
Do you work:
Do you feel you are getting:
Do you feel you are getting:
What forms of exercise?

What is your overall stress level?

	1	2	3	4	5

1 is Very Low, 5 is Super High

How do you deal with stress?
Your past and present UV exposure habits have a substantial impact on your skin condition, and must be considered in customizing treatments to be safe and effective for you.
Please check all statements that apply to you:

I sunbatheI use tanning bedsI'm outside a lotIn the past I tannedI wear daily SPFI avoid the sunI wear sunglassesI wear hats

When do you use the following types of sun protection?

	Never	Sometimes	Most Days	Every Day	Outdoor Activities
SPF 4-15 Tanning Products
SPF 15 or 20 Makeup
SPF 15 or 20 Moisturizer or Lotion
SPF 30 to 50 Sunscreen
SPF 50 or Higher Sunscreen

Hormonal factors have a substantial impact on skin condition and must be considered in determining safe and effective skincare treatments. Please check any of the following that apply to you:

PregnancyNursingHormonal ContraceptivesDiscontinued Hormonal MedicationMenopauseHormone Replacement TherapyPolycystic Ovarian SyndromePartial or Full HysterectomyHashimoto's or other Endocrine DisordersMiscarriagePubertyHormone ChangesOther
Type of Hormonal Contraceptive or HRT used:
Please check any of the following that you have had in the past 6 months:

BotoxFiller injectionsCosmetic SurgeryLaser treatmentsChemical peelingRadio Frequency or Ultrasound tighteningOther
If you checked any of the cosmetic procedures above, please list the date(s) of administration and any complications you experienced:
Do you have any electrical or metal implants, pins, or plates in your body, or do you have a heart condition, seizure disorder, or other condition which would limit your eligibiligy for electric-current skincare treatments? If yes, please explain:
Do you have any injuries, disabilities, areas of trauma or areas of sensitivity that your Esthetician should be aware of or avoid touching in order to keep you safe and comfortable? If yes, please explain:
Do you have any skin conditions, skin diseases, skin lesions, immune disorders, active infections, blood clots, bleeding problems, diabetes, lupus, current fever blisters/cold sores, or any other conditions that would limit your eligibility for skin care and waxing treatments? If yes, please explain:
Do you have any eye conditions, sensitive eyes, eye infections, or other conditions that would limit your eligibility for lash tinting treatments? If yes, please explain:
Are you allergic to aspirin?

YesNo
Are you pregnant, nursing, or trying to become pregnant?

YesNo
Do you have any additional concerns that were not addressed in this Health Intake? If so, please explain:
I understand, have read, and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritations to the skin from the treatments received. I am aware that it is my responsibility to inform the Esthetician of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release Spa Aeon, Aeon Aesthetics, LLC, Christine Giustra, and our employees, contractors, and agents from liability and assume full responsibility thereof. I understand that requests to cancel or reschedule appointments are gladly accommodated with 24 hours notice and that short-notice cancellations (less than 24 hours) and no-shows will be charged.
Signature:

Clear
spaaeon@gmail.com
example@example.com
Should be Empty: