Diarrhea/constipation
� Yes
� NoEczema
� Yes� No Where _________________________
Epilepsy
� Yes
� NoHay Fever� Yes
�NoHeadaches
� Yes
� No
How often _____________________
Heart Disease/Conditions
� Yes
� No
What___________________________
Hepatitis� Yes
� NoHIV/AIDS� Yes
� NoInfections
� Yes
� NoLupus
� Yes
� No
Menopausal
� Yes
� No
Metal Implants
� Yes
� NoPace Maker
� Yes
� No
SKIN ASSESSMENT
FORM
Phlebitis
� Yes
� NoSerious Injury
� Yes
� No
What __________________________
Sleep problems
� Yes
� NoFirst Name __________________________________
Last Name ___________________________________
Date __________
Thyroid� High� Low
� NormalVaricose
Veins
� Yes
� No
Performed
by _________________________________
Do you smoke?
� Yes
� No
PERIPHERALVASCULARSYSTEM& ITS DISORDERS � NoFATTY INCLUSIONS
Do
you wear contactlenses?
� Yes23. Have you ever had a reaction to� Cosmetics

ermanent redness)_____________________
� Fragrance� Airborneparticles?
______________________________________________________
24. FOR WOMEN: Oral contraceptives?
Are you pregnant or trying________________________
to get pregnant?
t redness) ____________________Are you taking hormone replacement?
Telangiectasia (distended capillaries) ______________
Do you experience hormone imbalances?
cularis) ______________________
25. FOR MEN: Do you shave with__
Do you experience skin breakouts?
_Do you have ingrown hair?

LIPID SYSTEM AND ITS DISORDERS

� Metals� Medication

� Food� Other Explain_____________________________
� Yes
� No
� Yes
� No
SKIN HYDRATION � No
� Yes
� Yes Normal hydration � No Superficial dehydration
� Electric shaver?
hydration � Razor?
� Yes
� No– Regions _____________________________________
� Yes
�No– Regions ___________________________________– Regions ___________________________________LIFESTYLE & DIET

SKIN SENSITIVITY
1. Is your stress level
� High� Medium� Lowegion(s) _______________________
2. Do you normally sleep well?
� Yes� NoRegion(s) _____________________
3. Do you regularly exercise?
� Yes� Notching)
4. Do you have food intolerances?
� Yes __
� NoWhat?____________________________-reative
5. Do you follow any special diet?
� Yes
� No
6. How many glasses of water do you consume daily? ______
7.ACNEHow many cups of caffeine-type beverage (coffee, tea, soft drinks) do you consume daily?
KERATINIZATION
� 1-3 cups
� 4 or more
8. In our treatment program, it may be necessary to recommend alterations to or additions in your home
- Region(s) _______________________________
care regimen; would that be OK with you?
� Yes
� Nol secretions: Region(s)- Region(s) _______________________________- Region(s) ________________________________-pustuleswill– Region(s)_______________________Your practitioner
recommend
the appropriate schedule for future facial treatments or physician referral
Keratosis senilis– Region(s)______________________________in order to achieve
yourskin improvement goals.

ERUPTION PATERNINFORMED CONSENT RELEASEGRAIN OF SKIN
SKIN TEXTURE

Acne GradeI _________________________________, do fully understand all the questions above and have answered themGrade 1:allcorrectly and honestly. I understand that the services offered are not a substitute for medical care. I
Grade 2: _____________________________________________
understand that the skin care professional will completely inform me of what to expect in the course of
Grade 3: _____________________________________________
treatment and will recommend adjustments to my regimen if deemed necessary. I also am aware that
Grade 4: _____________________________________________TONE I agree to actively participate
individual
results are dependent upon my age, skin condition,SKIN
and lifestyle.
Medically treated?
in following appointment schedules and home care proceduresmto the best of my ability, so that evere
I maylack of tone

Circadia by Dr. Pugliese, Inc.

84

Copyright 2018

Circadia by Dr Pugliese, Inc., 7139 Bernville Rd. Bernville, PA 19506
COPYRIGHT 2018 by PP CIRCADIA BY DR. PUGLIESE®. ALL RIGHTS RESERVED.

COMPLEXION & PIGMENTATION DISORDERS

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.
SKIN DISORDERS
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

SKIN GROWTHSFITZPATRICK CLASSIFICATION
Type I – WhiteType II – WhiteType III – WhiteType IV – Modest Brown
Type V – Dark Brown
Type VI – Black

Always burns easily, never tans
Burns easily, tans slightly
Sometimes burns, then tans
gradually and moderately
Burns minimally, always tans
wellBurns rarely, tans deeply
Almost never burns, deeply
pigmented

Circadia by Dr. Pugliese, Inc.

85

Copyright 2018

Circadia by Dr Pugliese, Inc., 7139 Bernville Rd. Bernville, PA 19506
COPYRIGHT 2018 by PP CIRCADIA BY DR. PUGLIESE®. ALL RIGHTS RESERVED.

Diarrhea/constipation� Yes
� NoEczema
� Yes� No Where _________________________
Epilepsy
� Yes
� NoTREATMENT
Hay
Fever RECORD FOR ______________
� Yes
�NoHeadaches
� Yes
� No
How often _____________________
Heart Disease/Conditions
� Yes
� No
What___________________________
Hepatitis
� Yes
� No
Date __________________ Esthetician ______________________
Date __________________ Esthetician _______________________
HIV/AIDS
� Yes
� NoToday’s Treatment _______________________________________
Infections
� Yes
� NoToday’s Treatment _______________________________________
Lupus
� Yes
� NoCleanser _______________________________________________
Cleanser _______________________________________________
Menopausal
� Yes
� No
TonerImplants_________________________________________________
Metal� Yes
� NoToner _________________________________________________
Pace
Maker______________________________
� Yes Time ___________ � NoExfoliation ______________________________ Time ___________
Exfoliation
Phlebitis
� Yes
� No
________________________
Extraction
Extraction
Serious Injury
� Yes
� No
What __________________________
Steam?
Sleepproblems
� Yes
� NoSteam?
Thyroid� High� Low� NormalHigh Frequency?
High Frequency?
Varicose Veins
� Yes
� NoGalvanicDo
you smoke?
� Yes
� NoGalvanicDo
you wear contact lenses?
� YesAmpoule?
________________ � NoAmpoule?
Masque?
Masque?
Time_________� Metals
23.
Have youWhat
ever ___________________________
had a reaction to� Cosmetics

What___________________________
Time_________
� Medication
� FoodMoisturizer
What ________________________________________
Moisturizer
What ________________________________________
� Fragrance� Airborne particles?
� OtherExplain_____________________________
Sunscreen
SPF ____
24.
FOR WOMEN: Oralcontraceptives?
Areservices
you pregnant
or trying to get pregnant?
Otherand comments:
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?

Sunscreen
SPF �____
� Yes
No
� Yes
� No
Other services and comments:
� Yes� No� Yes� No
� Electric shaver?
� Razor?
� Yes
� No
� Yes
� No

LIFESTYLE & DIET
1. Is your stress level
� High� Medium
� Low
2. Do you normally sleep well?
� Yes
� No
Esthetician ______________________
Date __________________ Esthetician _______________________
3.DateDo__________________
you regularly exercise?
� Yes
� No
4.Today’s
Do youhave foodintolerances?
� Yes
� NoWhat?____________________________
Treatment_______________________________________
Today’s
Treatment _______________________________________
5. Do you follow any special diet?
� Yes
� No
_______________________________________________
6.Cleanser
How many
glasses of water do you consume daily? ______Cleanser ________________________________________________________________________________________________
Toner_________________________________________________
7.TonerHowmany cups of caffeine-type beverage (coffee, tea, softdrinks)
do you consume daily?
�1-3cups�
4
ormoreExfoliation ______________________________ Time ___________
Exfoliation ______________________________ Time ___________
8. In our treatment program, it may be necessary to recommend alterations to or additions in your home
Extraction
Extraction
care regimen; would that be OK with you?
� Yes� NoSteam?

How long ____________________________

Steam?

Yourfuture
facial treatments or physician referral
Frequency?
Highpractitioner
Frequency?will recommend the appropriate schedule forHighinGalvanic
order to achieve your skin improvement goals.
Galvanic
Ampoule?

Ampoule?

INFORMEDRELEASE
Masque? CONSENT
What ___________________________
Time_________
Moisturizer What ________________________________________

Masque?

What ___________________________ Time_________

Moisturizer What ________________________________________

Sunscreen
SPF ____
Sunscreen
SPF____have answered them
I _________________________________,
do fully understand all thequestions above
and
allOthercorrectly
andhonestly.
I understand that the services offered
not asubstitutefor medical care. I
services
andcomments:
Other areservices
andcomments
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

Circadia by Dr. Pugliese, Inc.

86

Copyright 2018

Circadia by Dr Pugliese, Inc., 7139 Bernville Rd. Bernville, PA 19506
COPYRIGHT 2018 by PP CIRCADIA BY DR. PUGLIESE®. ALL RIGHTS RESERVED.