CONSULTATION FORM Name * First Name Last Name Email * DOB * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### How were you referred to us? Occupation: YOUR SKIN CARE Does your job require that you work outdoors? YES NO What would you like to achieve from your treatment today? When was your most recent facial? Which of the following best describes your skin type? (Please check one) Type I: Fair skin tones—Always burns, never tans Type II: Light skin tones—Burns easily, tans slightly Type III: Fair to olive skin tones—Burns moderately, tans moderately Type IV: Light brown skin tones—Burns slightly, tans easily Type V: Dark brown skin tones—Rarely burns, tans easily Type VI: Dark brown skin tones—Rarely burns, tans easily Do you have any special skin problems or concerns pertaining to your face or body? * YES NO If yes, please specify: Have you ever had chemicals peels, laser treatments, or microdermabrasion? YES NO In the last month? YES NO Do you use Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/vitamin A derivative products? YES NO If yes, please specify what and when last used: 7) Have you used acne medication? If so, which medication and when? 8) Have you experienced Botox, Restylane, or collagen injections? YES NO If so, please specify: 9) What skin care products are you currently using? (List brands if known) CLEANSER, TONER, MOISTURISER, EXFOLIATOR, MASK, EYE CREAM, SPF, SCURBS MAKEUP PRODUCTS, SOAP, SHOWER GELS, BODY LOTIONS, OTHER: 10) Have you used any hair removal methods in the past six weeks? YES NO If so, please specify: Areas of concern regarding your skin? SKIN Breakouts/acne Sun damage Rosacea Flaky skin Sun/liver/brown spots Uneven skin tone Excessive oil/shine Dull/dry skin Redness/ruddiness Blackheads/whiteheads Wrinkles/ fine lines Broken capillaries Dehydrated Areas of concerns regarding your eyes? CHECK ALL THAT APPLY Dehydrated Dark circles Wrinkles Puffiness Other Area of concern with your lips? CHECK ALL THAT APPLY Dehydrated Cracked/ chapped lips 12) Have you ever had an allergic reaction to any of the following (Check all that apply) CHECK ALL THAT APPLY Cosmetics Fragrance Animals Drugs AHAs Food Latex Iodine Medication Shellfish Sunscreens Pollen Other: If so, please specify: 13) What SPF do you use on your face? HOW OFTEN DO YOU APPLY? 14) Have you recently used any self-tanning lotions, creams or treatments? YES NO If so, please specify: 15) Have you had any recent tanning bed or sun exposure that changed the color of your skin? YES NO If so, please specify: LIFE STYLE 16) How many glasses of water do you drink per day? PLEASE CHECK ONE <1 glass 1-3 glasses 4-7 glasses 8+ glasses 17) How many caffeinated beverages (coffee, tea, soda, etc.) do you consume per day? PLEASE CHECK ONE None 1-2 drinks 3-5 drinks 6+ drinks 18) How many alcoholic beverages do you consume per week? PLEASE CHECK ONE I don’t drink 1-3 drinks 4-7 drinks 8+ drinks 19) How many hours of sleep do you get per night? PLEASE CHECK ONE <3 hours 3-5 hours 6-8 hours 8-10 hours 10+ hours 20)Which foods do you consume on a regular basis? Fruits Vegetables Dairy/Eggs Cheese Poultry Fish Grains/Bread ProcessedSugar ProcessedMeats 21) What does your daily commute look like? Car Bike Public Transport Walk I don’t commute 22) How often do you travel on a plane? Never 1-2 times per year 1-2 times per quarter Every month Every week 23) How many hours do you spend in front of a screen or digital device? <3 hours 4-6 hours 7-9 hours 10-12 hours 24) Do you exercise on a regular basis? YES NO 25) Do you smoke cigarettes, vape, or consume other tobacco products? YES NO 26) What are your stress levels on a scale from 1 to 5? (1 = low stress, 5 = high stress) FEMALE 27) Are you taking oral contraceptives? If so, please specify: 28) Any recent changes to or from your contraceptive treatments? If so, please specify: 29) Are you pregnant or trying to become pregnant? YES NO 30) Are you experiencing any menopausal symptoms? If so, please specify: 31) Are you undergoing any hormone replacement therapy treatments? If so, please specify: MALE 32) Do you experience irritation from shaving? If so, please specify: 33) Do you experience ingrown hairs as a result of hair removal? YES NO DISCLOSURE 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/skin care professional from liability and assume full responsibility thereof. I AGREE YES NO NAME First Name Last Name DATE MM DD YYYY Thank you!
