Skin Care History Questionnaire

Name*

First Middle Last

Referred by

Please check if presently using any of the following.*

(please X all that apply)

NONE
Accutane within the past 1-2 years
Glycolic Acid/Alpha Hydroxy Acid
Topical Vitamin C
Hydroquinone
Retinoid (Vitamin A derivatives) i.e. Retin A, Renova, Differin

Have you ever had an allergic reaction to any skin product or cosmetic?*

Yes
No

Female Assigned

Are you going through menopause?

Yes
No

Are you on hormone-replacement therapy

Yes
No

Are you presently taking birth control pills?

Yes
No

Are you pregnant or planning to be?

Yes
No

Are you in a fertility program?

Yes
No

All Clients

Have you seen a dermatologist in the past year?*

Yes
No

Have you had electrolysis or waxing in the past week?*

Yes
No

Do you have hepatitis?*

No
A
B
C

Do you faint easily?*

Yes
No

Have you ever had herpes (cold sores)?*

Yes
No

Have you ever been treated with Zovirax or any medication for herpes?*

Yes
No

Do you currently have or have had in the past any skin cancers?*

Yes
No

If yes, where and when

Do you have or have you ever had acne?*

Yes
No

How often do you experience breakouts?*

Frequently
Occasionally
Rarely
NA

What type of blemishes do you experience?*

Whiteheads
Backheads
NA

Are you using or have you ever used any medications for acne?*

Yes
No

Name of medication

Do you have epilepsy or diabetes?*

If yes, you will be treated only with a doctor’s release!

Yes
No

Have you had any of the following?*

(please X all that apply)

When was this?*

Have you had any of the following?*

(please X all that apply)

Select All
Hyperpigmentation (Brown Spots)
Acne/Acne Scarring
Sun Damage
Enlarged Pores
Fine Lines & Wrinkles
Age Spots
Surgical Facial Scars
Other

Are you allergic to aspirin?*

Yes
No

Are you allergic to iodine or seaweed?*

Yes
No

Do you have any other allergies?*

Yes
No

If yes, list:*

Do you smoke any of the following?*

No I do not smoke
Cigarettes
Marijuana
E-cigarettes

Do you drink alcoholic beverages?*

Yes
No

How many drinks per week*

Do you use a tanning bed?*

Yes
No

Do you use self tanners?*

Yes
No

Do you take nutritional supplements?*

Yes
No

Do you wear contact lenses?*

Yes
No

Would you consider your dairy intake:*

How many ounces of water do you drink per day*

Do you have broken capillaries?*

Yes
No

If so, where*

Have you had electrolysis or waxing in the past week?*

Yes
No

Do you blush easily?*

Yes
No

Which conditions do you want to improve*

(please X all that apply)

Select All
Hyperpigmentation (Brown Spots)
Acne/Acne Scarring
Sun Damage
Enlarged Pores
Fine Lines & Wrinkles
Age Spots
Surgical Facial Scars
Other

Have you had permanent cosmetics?*

Yes
No

If yes, where?*

In the morning I use:*

(please X all that apply)

Select All
Cleanser
Serums
Vitamin C
Eye cream
Moisturizer
NA

In the evening I use:*

(please X all that apply)

Select All
Cleanser
Serums
Vitamin C
Eye cream
Moisturizer
NA

The products I use are:*

(please X all that apply)

Select All
Over the counter
Purchased at a spa
Medical grade/physician dispensed

Do you use a sunscreen/sunblock?*

Yes
No

If yes, what SPF:*

Which brand?*

What kind of exfoliating treatments do you use at home and how often:

Do you use any topical medications (prescriptiong pharmeceuticals; including Retin-A, hydroquinone, Accutane, Benzoyl perioxide, Metrogel, Efudex, Cortisone, glycolic acid, lactic acid, salicylic acid, etc.)

What are your skincare goals?

Is there any other information I should know before beginning your treatment?

Are you over the age of 18?*

Yes
No

If you experience any issues or complication after the conclusion of your appointment you must contact the office or your esthetician within 72hrs of your appointment.

Parent’s Printed Name*

Parent’s Signature*

Client’s Printed Name*

Client’s Signature*

Today's Date*

Phone

This field is for validation purposes and should be left unchanged.