CONFIDENTIAL SKIN HEALTH QUESTIONNAIRE
PLEASE PRINT

Today’s Date _____________________________First Name _______________________________Last Name _____________________ Date of Birth ____/____/_______
Street ___________________________ Apt. # ______ City __________________ State ________ Zip _______________
Phone – Home () ______________ Work ()_________________ Mobile (Dermatologist/physician _____________________________________ Phone (Emergency Contact ______________________________________ Phone () _______________________) __________________________) _______________________________Your occupation _________________________________________E-Mail _______________________________________
Referred by

� Friend

� Mailer� Walk-by

� E-mail�Gift Certificate

� Other________

Skin Care Professional Name:___________________________________________________________________________________________
1. What is the reason for your visit today?_______________________________________________________________
2. What special areas of concern do you have?_________________________________________________________EXPECTATIONS and HISTORY
3. Which conditions would you like to improve?
�Acne scarring�Hyperpigmentation

�Acne

�

Broken capillaries

�Age spots

�Stretch Marks

�Enlarged Pores�

Surgical/facial scars

�Fine lines & wrinkles

�

Other ___________________

4. Have you ever had facial treatment in the past?

� Yes

� No

5. What was your experience?________________________________________________________________________
6. How would you describe your skin?
� Normal� Dry� Oily� Combination

�Sensitive� Sun Damaged

7. How would you rate your skin? (Circle one)
I Always burns, never tans
II Always burns easily, tans slightly
III Burns moderately – tans gradually
IV Seldom burn – Always tans well
V Rarely burns – Deep tan
VI Never burns – Deeply pigmented

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8. Do you ever experience� Flakiness?

� Tightness?

� Redness?

� Excessive oily shine during day?

9. What is your present skin regimen?
� Soap & water only

� Cleanser

� Toner� Masque� Moisturizer� Exfoliation

� Sun Block every dayOther______________________________________
10. Are you ever exposed to chemicals, oils, or other caustic substances that may aggravate your skin?
� Yes

� No

If yes, what are they?__________________________________________________________________________________
11. Do you blush easily?

� Yes

� No

If yes, what are the contributing factors?
� Emotions
12. Do you� Foods

� Temperature changes

� Sun bathe?

� Use a tanning bed?

13. Have you ever had

� Peels?

� Cosmetic Surgery

� Other _______________________How often?___________________________________

� Microdermabrasion

� Botox� Facial surgery

� Collagen Injections

� Laser resurfacing

How recently?__________
14. Are you under treatment for any current skin condition?

� Yes

� NoIf yes, what?_______________________________________________________________________________________
15. Does your skin heal� Fast?

� Scars?

16. Do you bruise easily?

� Yes

� No

17. Do you get sores/blisters (Herpes Zoster/Shingles)?

� Pigments?

� Yes

� No

18. What medications/hormone replacement/vitamins do you presently take?
________________________________________________________________________________________________________
19. Have you ever used
� Topical Antibiotics

� Accutane®
� Differin

� Retin-A®

� Tazarac� Renova®

� Hydroquinone� Alpha Hydroxy Acids?

If yes, when and for how long? ______________________________________________________________
20. Any personal or family history of skin cancer?

� Yes

� No

Provide detail _________________________________________________________________________________
21. How would you describe your overall health?
� Excellent

� Good� Fair� Poor

22. Have you had any of the following, past or present?
Acne
Allergies
Arthritis or Bursitis
Blood Pressure
Breast Implant
CancerCataracts
Cholesterol
Claustrophobic
Diabetes

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� Yes
� Yes
� Yes
� High� Yes
� Yes
� Yes
� High� Yes
� Yes� No� No� No
� Low
�No
� No� No
� Low
� No
� No81

When _________________________
� Normal� Normal

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Diarrhea/constipation
EczemaEpilepsy
Hay FeverHeadaches
Heart Disease/Conditions
Hepatitis
HIV/AIDS
Infections
Lupus
Menopausal
Metal Implants
Pace Maker
Phlebitis
Serious Injury
Sleep problems
Thyroid
Varicose Veins
Do you smoke?
Do you wear contact lenses?

� Yes
� Yes
� Yes
� Yes
� Yes
� Yes
� Yes
� Yes
� Yes
� Yes
� Yes
� Yes
� Yes
� Yes
� Yes
� Yes
� High� Yes
� Yes
� Yes

23. Have you ever had a reaction to� Fragrance

� No
� No Where _________________________
� No
�No
� No
How often _____________________
� No
What___________________________
� No
� No
� No
� No
� No
� No
� No
� No
� No
What __________________________
� No
� Low
� Normal
� No
� No
� No
� Cosmetics

� Airborne particles?

24. FOR WOMEN: Oral contraceptives?
Are you pregnant or trying to get pregnant?
Are you taking hormone replacement?
Do you experience hormone imbalances?
25. FOR MEN: Do you shave with
Do you experience skin breakouts?
Do you have ingrown hair?

� Metals� Medication

� Food� Other Explain_____________________________
� Yes
� Yes
� Yes
� Yes
� Electric shaver?
� Yes
� Yes

� No
� No
� No
� No
� Razor?
� No
� No

LIFESTYLE & DIET
1.
2.
3.
4.
5.
6.
7.
8.

Is your stress level
� High� Medium� Low
Do you normally sleep well?
� Yes
� No
Do you regularly exercise?
� Yes
� No
Do you have food intolerances?
� Yes
� NoWhat?____________________________
Do you follow any special diet?
� Yes
� NoHow many glasses of water do you consume daily? ______How many cups of caffeine-type beverage (coffee, tea, soft drinks) do you consume daily?
� 1-3 cups
� 4 or more
In our treatment program, it may be necessary to recommend alterations to or additions in your homecare regimen; would that be OK with you?
� Yes
� NoYour practitioner will recommend the appropriate schedule for future facial treatments or physician referralin order to achieve your skin improvement goals.
INFORMED CONSENT RELEASE
I _________________________________, do fully understand all the questions above and have answered them
all correctly and honestly. I understand that the services offered are not a substitute for medical care. I
understand that the skin care professional will completely inform me of what to expect in the course oftreatment and will recommend adjustments to my regimen if deemed necessary. I also am aware that
individual results are dependent upon my age, skin condition, and lifestyle. I agree to actively participate
in following appointment schedules and home care procedures to the best of my ability, so that I may

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obtain maximum effectiveness. In the event that I may have additional questions or concerns regarding
my treatment or suggested home product routine, I will inform my skin care professional immediately.
I release and hold harmless the skin care professional [insert your name], [insert business name], and thestaff harmless from any liability for adverse reactions that may result from this treatment.
POLICIES
1. We require 48-hours notice for cancellations. Cancellation for Monday must be phoned in on the Friday
before.
2. If you are not satisfied with your service or products, please contact your skin care professional within 24hours after your appointment so that the situation may be corrected. It is our policy to provide you withthe best professional service and products customized for your skin condition.
I have read and understood all of the foregoing information ____________________________ Date ___________
Client Signature

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