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Confidential Skin Health Intake Form
Please Print:
Date _________________________ Home phone________________________ Name ________________________ Work phone ________________________ Address _______________________ Cell phone _________________________ ______________________________ Email _____________________________ Date of Birth _________Age______ Emergency Contact and phone__________ Occupation ___________________ ___________________________________ Does your work require you to be outdoors? Yes No
Referred by: _______________________________________________________________
Your Skin Care
1) Have you ever had a facial treatment before? Yes, when? ________ No 2) Have you ever had a body spa treatment before? Yes, when? ________ No Massage: Yes No Salt glow: Yes No Seaweed wrap: Yes No Moor mud: Yes No Body scrub: Yes No Other: _________________________________________ 3) Are you currently under the care of a physician? Yes No If yes, for what? ___________________________________________
4) Do you have any special skin problems or concerns pertaining to your face or body? Yes No Specify: __________________________________________
5) Have you ever had chemical peels, laser, or microdermabrasion? Yes No In the last month? Yes No
6) Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products? Yes No describe: _______________________________ Have you used this in the last 3 months? Yes No
7) Have you used any acne medication? Yes, when? _________which drug? _________ No
8) Please list any medications you are currently taking. Please indicate oral: ________________________________________________________________________ topical:______________________________________________________________________
9) What skin care products are you currently using? (list brand where know) Soap ____________________________ Shower Gels _________________________ Toner ___________________________ Body Lotions _________________________ Mask ___________________________ Sunscreen __________________SPF______ Eye product _____________________ Night Moisturizer _____________________ Cleanser ________________________ Makeup Products______________________ Day Moisturizer __________________ _____________________________________ Exfoliant_________________________ _____________________________________ Scrubs __________________________ Other _______________________________
10) Skin: (Please check any that apply and explain) Breakouts/acne Uneven skin tone Blackheads/whiteheads Sun Damage Excessive oil/shine Wrinkles/fine lines Rosacea Dull/dry skin Broken capillaries Flaky skin Redness/ruddiness Dehydrated Sun spots/liver spot/brown spot Other: ________________________
Eyes: dehydrated wrinkles puffiness dark circles Other: _______________ Lips: dehydrated cracked/chapped Other: _______________
11) Please circle the following if it pertains to you: Chemical or laser peels Follow a restricted diet Rein-A or Accutane Exercise regularly Use glycolic, AHA, or salicylic acids Irregular sleep patterns Reddens easily History of melanoma or basil cell carcinoma Wax regularly Wear contact lenses Ingrowns or irritation w/ hair removal Currently menstruating or due to Flush with intake of spicy food or alcohol Burn easily in moderate sunlight Currently using oral contraceptives Wear sunscreen every day Hormone replacement therapy menopause symptoms Currently lactating Pregnant or trying to become pregnant Botox, Restylane or Collagen injections
12) Have you had any recent tanning exposure, tanning beds, or self-tanning treatments that changed the color of your skin? Yes No If yes, specify: _________________________________________________________
13) What SPF do you use on your face? ________________ How often/when? _______________________
14) What SPF do you use on your body?________________ How often/when? _______________________
15) Which of the following hair removal methods do you use: Shaving Waxing Electrolysis Tweezing Stringing Depilatories Laser None
16) Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain) cosmetics AHAs medicine fragrances food shellfish animals latex sunscreens drugs iodine pollen Other: _____________________
If yes, please explain: ___________________________________________________________________
17) What are your specific goals or special concerns for your treatment today? _____________________
____________________________________________________________________________________
Future Appointments/Contact: May I call you at your home, work or cell phone number to confirm future appointments? Yes No
May I contact you via mail/email about future promotions and news? Yes No
I understand that the services offered are not a substitute for medical care, and any information provided by the therapist is for educational purposes only and not diagnostically prescriptive in nature. I understand that the therapist does not diagnose, treat, or prescribe for any illness, aliment or disease. I understand the information herein is to aid the therapist in giving better service and is completely confidential.
Policies: Please arrive on time and allow 24 hours notice for cancellation or appointment changes. I understand there is a $50 fee if I miss an appointment, to be paid on the following appointment scheduled. Refunds are not given except in case of defective merchandise. 30 day return policy please.
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 skin care professional from liability and assume full responsibility thereof.
Client Signature ___________________________________________ Date ________________
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