Client Intake Form
REQUIRED FOR ALL FACIAL TREATMENTS PRIOR TO APPOINTMENT
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Sex:
*
Female
Male
Other
How were you referred to us?
Does your job require you to work outdoors?
*
YES
NO
What would you like to achieve from your treatment today?
*
Your Health
Please answer all questions truthfully and to the best of your knowledge
Within the last year, have you been under a dermatologist’s or other medical physician’s care?
*
Yes
No
If yes, please specify:
Have you had any health problems in the past or present?
*
Yes
No
If yes, please specify:
Have you ever been treated for cancer?
*
Yes
No
If yes, please specify:
Are you using any blood/skin thinning products and/or drugs?
*
Yes
No
If yes, please specify:
Have you used an acne medication?
*
Yes
No
If yes, please specify:
When and list medication
Do you have any allergies?
*
Yes
No
If yes, please specify:
Have you had any recent surgery, including plastic surgery?
*
Yes
No
If yes, please specify:
List any medications, supplements, vitamins, diuretics, slimming pills, Accutane, etc that you take regularly?
*
Do you smoke?
*
Yes
No
Do you exercise regularly?
*
Yes
No
Do you follow a restricted diet?
*
Yes
No
How many glasses of water do you drink per day??
*
>1 glass
1-3 glasses
4-7 glasses
8+ glasses
How many caffeinated beverages (coffee, tea, soda, etc.) do you consume per day?
*
None
1-2 drinks
3-5 drinks
6+ drinks
How many alcoholic beverages do you consume per week? (Please check one)
*
I don't drink
1-3 drinks
4-7 drinks
8+ drinks
Do you wear contact lenses?
*
Yes
No
Do you sunbathe or use tanning beds?
*
Yes
No
Are you claustrophobic?
*
Yes
No
Rate your stress level on a scale of 1 to 5
*
Low
1
2
3
4
High
5
1 is Low, 5 is High
Your Skin
Have you ever had a facial treatment before?
*
Yes
No
If yes, please specify when:
What areas of concern do you have regarding your: Skin (Check all that apply)
*
Breakouts/Acne
Uneven skintones
Blackheads/Whiteheads
Sun Damage
Excessive Oil/Shiny
Wrinkles/ Fine lines
Roseacea
Dull/ Dry Skin
Broken Capallaries
Flaky Skin
Redness/ Ruddiness
Dehydration
Sun/liver/brown spots
None
Other
Have you ever experienced the following conditions on your skin?
*
Flakiness
Tightness
Obvious dryness
None
Eyes (Check all that apply)
*
Dehydrated
Wrinkles/fine lines
Puffiness
Dark circles
Other
Lips (Check all that apply)
*
Dehydrated
Cracked/Chapped
Other
Do you have metal implants, a pacemaker or body piercings?
*
Yes
No
What skin care products are you currently using on your face? Please check all that apply.
*
Soap
Cleanser
Toner
Moisturizer
Masque
Exfoliator
Eye Products
None
Have you ever had chemical peels, microdermabrasions, laser treatments or any resurfacing treatments in the last month?
*
Yes
No
Have you experienced Botox, Restylane, or collagen injections?
*
Yes
No
Do you use Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/vitamin A derivativeproducts??
*
Yes
No
If yes, when was last use?
Are you currently using any products that contain the following ingredients?
*
Glycolic acid
Lactic acid
Exfoliating scrubs
Hydroxy acid products
Vitamin A derivatives (ie., Retinol)
None
Have you ever had an adverse reaction after using any skin care product?
*
Rash
Irritation
Peeling
Sun Sensitivity
Breakout
None
What SPF sunscreen do you use on your face?
Do you burn easily in moderate sunlight?
*
Yes
No
Do you suffer from sinus problems?
*
Yes
No
Female Clients Only
Are you taking oral contraception?
*
Yes
No
N/A
Are you pregnant?
*
Yes
No
N/A
Male Clients Only
Do you have shaving challenges?
*
Yes
No
If yes, please specify:
Do you experience ingrown hairs as a result of hair removal? ?
*
Yes
No
Questions to discuss every visit
Have you started any new medications since your last visit?
Yes
No
If yes, please specify:
*Confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. 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.The treatments I receive here are voluntary and I release this institution and/or the technician/esthetician/skincare professional from liability and assume full responsibility thereof.
*
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