New Client Skincare Consultation Form

Botanic Zen Aesthetics Online Skincare Consultation Form
Date*

MonthDayYear
Name*

First NameLast Name
Date of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
E-mail*
example@example.com
How did you hear about me?*

Website / Online SearchInstagramFacebookReferralOther
If Referral, please list name
If Other, please let me know
Your Skin
What are your skin care goals? *
What are your skin care challenges?*

Wrinkles / Fine LinesHyperpigmentation / Sun DamageAcne / Acne ScarringRedness / RosaceaAgingMelasmaSensitivityOther
Please feel free to go into more detail
Have you ever had a facial or skin treatment before?*

YesNo
If Yes, when?

What skin care products do you currently use? Please detail the SPECIFIC products (BRAND & PRODUCT TYPE/NAME) you are currently using so I can best answer any questions on ingredients and help you meet your skin care goals.*

	Brand + Product Name/Type
Cleanser / Face Wash
Toner
Serums
Moisturizers
Sunscreen
Mask
Foundation
Blush
Exfoliants (acids, serum, scrubs)
Acne Medications
Eye Procucts
Anything Else?

Other Treatments-Have you received any of these treatments in the last 30 days?

	When?	Where?
Chemical Peels
Microdermabrasion
Dermabrasion
Laser Hair Removal
Laser Rejuvenation/Resurfacing
Skin Cancer Removal
Facial Waxing
Electrolysis

Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks?*

YesNo
Your Health-Medical History

(Please check all that apply)
Your Primary Care Physician:
Are you under a dermatolgist's or other physican's care?*

YesNo
If yes, doctor's name?
Have you experienced any of these health conditions in the past or present?*

Hormone ImbalanceDiabetesAuto-Immune DisordersEpilepsy / Seizure DisorderFever BlistersFrequent Cold SoresDepression/AnxietyHepatitisHeadaches / MigrainesEczemaPsoriasisCancerStaph Infection/MRSAHIV/AIDSThyroid ProblemsHysterectomyOvary(ies) RemovedPacemakerHemophiliaLupusAnemiaHigh Blood PressureOtherNone
Medications*

AntibioticsAccutaneBenzoyl PeroxideRetin ATazoracDifferinAzelexAvitaCleocin-TE-mycin-TCopaxoneCorticosteroidsQuinineAndrostendioneTestosteroneProgesteroneGonadotropinDanzolCyclosporineLithiumIsoniazidImmuranDisulfuramDilantin/TegretolSteroidsMarijuanaOther MedsNone
If you checked yes to any of these please provide further information. If not mark N/A*
Do you take any of the following dietary / health supplements?

MultivitaminVitamin CVitamin D/D3ZincOmega 3 / Fish OilB Complex / B12GarlicCalciumFolic AcidMelatoninCoenzyme Q10BiotinOtherN/A
If other, please list
Any known allergies?*

SulfurAspirinLatexTree NutsDairyFruitsVegetablesShellfishIodineFragrances / Essential OilsOtherNone
If Other, please specify
Have you used or been prescribed any medications (topical or oral) for acne / acne control?*

YesNo
If yes, please specify what and date last used
Lifestyle Considerations
Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*

YesNo
Do you smoke?*

YesNoSocial
Have you ever experienced claustrophobia? *

YesNo
Please rate your stress level (common stress = job loss, new job, wedding, romantic breakup, death in family or close friend, graduation, difficult home life, long commute, heavily scheduled).*

LowMediumHigh
Have you ever had any reaction to any products or anything you have put on your face?*

YesNo
Do you use fabric softener or fabric softener sheets in the dryer?*

YesNo
Do you swim in a chlorinated pool?*

YesNo
Do you work around chemicals, tars, oils, grease, or ink?*

YesNo
Occupation?
Do you work nights?*

YesNo
FEMALE CLIENTS
Are you taking birth control? *

YesNoN/A
If yes, what kind
Are you pregnant or trying to become pregnant?*

YesNoRecently had a baby and am breastfeedingN/A
Are you undergoing any hormone replacement therapy?

YesNoN/A
If yes, please specify
MALE CLIENTS
What is your current shaving system? *

Razor / Wet shaveElectricN/A
Do you experience irritation from shaving? *

YesNoN/A

Botanic Zen Aesthetics Online Skincare Consultation Form

Your Skin

Your Health-Medical History

Lifestyle Considerations

Informed Consent