Skin and Health Questionnaire

Please complete the following as thoroughly and

in as much detail as possible.

The information will be used to prepare in advance for your service.

First name

Last name

Birthday

Month

Day

Year

Phone

Email

Address

Emergency contact name

Emergency contact phone number

What would you like to change about your skin?

Skin Self-Analysis

Please answer to the best of your knowledge

Have you ever treated or been treated for a skin condition? If yes, what condition?

How did you treat the condition?

Dermatologist

Esthetician

Self-treated with products from drug store

Self-treated with products bought at a department store

Were you happy with the result:

Yes

No

Partially happy

Are you currently treating or being treated for any skin condition?

*Crucial* Please list all cosmetic products you are using including Brand name, Product name/type, and frequency of use (if possible). You can also simply text photos of your products to Anna's cell directly @ 909.573.1246(please include your full name).

Female clients only

Are you pregnant or trying to become pregnant:

Yes

No

Do you use any hormonal birth control methods:

Yes

No

Are you currently on any type of other hormonal therapy? If yes, please, describe:

Do you have regular periods:

Yes

No

Are you going through menopause:

Yes

No

Do you have any hormonal imbalances you are aware of? If yes, please indicate:

Have you undergone surgical menopause (hysterectomy)?

Yes

No

Medical history

Any other conditions:

Any known allergies?

Any recent surgeries, including plastic surgery?

List any medications you take regularly, including vitamins, herbal supplements and aspirin:

What condition were you treating with this medication(s)?

When was the last time you used these medication(s)?

Lifestyle

How much water do you drink per day?

Caffeine intake:

No caffeine

1-2 cups a day

3-5 cups a day

More than 5 cups a day

Carbonated drinks?

Yes, minimum consumption

Yes, moderate consumption

Yes, heavy consumption

No

Do you smoke? Vape?

Yes

No

Occasionally

How many minutes a day are you exposed to sunlight?

Do you exercise? If yes, how often?

Average hours of sleep?

How would you describe your stress level from 1 to 10?

Average alcohol consumption per week?

Do you use a tanning bed? If yes, how many minutes a week?

Have you changed your brand of skin care products in the last year? If yes, why did you change?

Would you like to mention anything else to your esthetician that was not addressed above?

By signing below, you agree to the following:

I have filled out this form as completely and truthfully as I can. I consent to update the technician on any changes to the previously provided information. I consent to release my technician and the employer from all liability for any harm or losses brought on by any falsification of my medical history.

Signature of patient or responsible party:

Signature field is empty.

Date