Skincare Questionnaire
Please fill in the form below.
Full Name
*
First Name
Last Name
Today's Date
-
Month
-
Day
Year
Date
Are you under the care of a dermatologist?
Yes
No
If yes, please specify
Are you using any Retin A or Retinols? (topically or internally)
Yes
No
If yes, please specify
Have you had any of the following facial procedures done?
Plastic surgery
Botox and/or other fillers
IPL or laser treatments
Other
Select all skincare product types you use in your homecare routine?
Cleanser
Toner
Serum
Face oil
Moisturizer
SPF
Masque
Exfoliation
Night Cream
Soap
Lotion
None
Other
If any of your skincare products contain an active ingredient, please specify.
(Salicylic acid, etc.)
How would you rate your skin's sensitivity?
1
2
3
4
5
Low
High
1 is Low, 5 is High
Do you apply an SPF daily?
Yes, just once.
Yes, and I reapply every 2 hours.
Yes, only when I know I'll be exposed to the sun.
No.
What brands of skincare and/or makeup do you use?
What are your skincare concerns? (Mark all that apply.)
Aging, fine lines and wrinkle
Acne, oily, breakout prone
Dry/Dehydrated
Rosacea
Large pores
Hyperpigmentation, scars and spots
Texture, rough, bumpy, pitting
Dull complexion
Sun damage
Inflammation
Hormonal skin
Other
Do you scar easily?
1
2
3
4
5
Not likely
Very likely
1 is Not likely, 5 is Very likely
How many glasses of water do you drink daily?
1-2
3-5
6-9
10 or more
Do you consume: (daily)
More than 30g of Sugar
Dairy
Gluten
How many alcoholic beverages do you consume weekly on average?
None
1-3
4-6
7 or more
Are you taking birth control medication?
Yes
No
Are you pregnant or trying to become pregnant?
No
Yes
Currently breatfeeding
Gave birth within the last year
Do you have any hormonal issues or imbalances?
PCOS
Menopause
Hormone Replacement Threapy
Other
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 irritation to the skin from treatments received. I am aware that it is my responsibility to inform the professional of my current medical or health conditions and to update this history as needed. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.
*
I have read and understand the conditions.
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