Skin Care EvaluationRequired of ALL clients. If you would prefer to print this form and fill it out by hand, please click here. Name * First Name Last Name Date of Birth * MM DD YYYY Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Health History Are you currently under the care of a physician? * Yes No If yes, why? Have you ever seen a dermatologist or other physician for your skin? * Yes No If yes, why? Have you ever been treated with injectable fillers? (Botox, Collagen, etc)? * Yes No If yes, when? And location(s)? Are you using Retin-A or any other topical drugs or treatment products? * Yes No If yes, list each used: Please list any oral medications you currently take. * Please list any vitamins, minerals, and nutritional supplements (topically or internally) you are currently using. * How many ounces of water do you consume daily? * Do you smoke? If yes, how much? * Do you drink? If yes, how much? * Do you have any broken capillaries? (Check all that apply) Nose Chin Cheek Forehead Entire Face Acne Do you have any history of acne or periodic breakouts? * Yes No If yes, check all that apply. Pimples White heads Black heads Cysts Acne scars Enlarged pores Are you now or have you ever taken Accutane? When was it last taken? * Women: do you only experience breakouts around the time of your menstrual cycle? Yes No Men: do you experience irritation or breakouts due to shaving? Yes No Skin type Is your skin shiny a few hours after cleansing? * Frequently Occasionally Rarely Does your skin ever flake or feel tight and dry? * Frequently Occasionally Rarely How often do you experience blemishes? * Frequently Occasionally Rarely How noticeable are your pores? * Very T-Zone Not Very Sun history How do you tan? * Burn Usually burn Sometimes burn Rarely burn Never Do you spend significant time in the sun? * Yes No Do you use sunscreen all day everyday? * Yes No Are you willing to use sunscreen everyday? * Yes No Have you or any member in your family ever had skin cancer? If yes, who? Anatomical location? * Pigmentation: * Even Uneven Pregnancy mask Birthmark Ability to heal Do you have any problems healing from a cut or burn? If yes, explain. * Do you have any health problems? If yes, explain. * Have you EVER had a cold sore? If yes, when was the last sore? * Do you use wax or depilatories on your face? If yes, when last used? * Have you ever had a professional peel or microdermabrasion? If yes, when? Results? * What changes and improvements would you like seen on your skin? * What specific areas do you want to treat? * Face Neck Chest Back Other Describe your morning and evening routine for face: * Describe your morning and evening routine for body: * Do you ever wear contact lenses? * Yes No Acknowledgment and submission I acknowledge that the questions answered above are true and my Esthetician/Therapist cannot be held responsible for any reactions that would otherwise been prevented. * Yes Thank you!
