How were you referred to us?

Does your job require that you work outdoors?

Yes

What would you like to achieve from your treatment today?

Have you ever had a facial treatment before?

Yes

Have you ever had a body spa treatment before?

Yes

If yes, please specify when and what treatment:

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 to black skin tones—Never burns, tans easily

Do you have any special skin problems or concerns pertaining to your face or body?

Yes

If yes, please specify

Have you ever had chemicals peels, laser treatments, or microdermabrasion?

Yes

In the last month?

Yes

Do you use Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/vitamin A derivative products?

Yes

If yes, please specify what and when last used

Have you used acne medication?

Yes

If yes, when and which medication?

Have you experienced Botox, Restylane, or collagen injections?

Yes

If yes, please specify which

Please list what skin care products are you currently using? (List brands if known)

Cleanser
Toner
Day Moisturizer
Night Moisturizer
Exfoliator
Mask
Eye Product
SPF/Sunscreen
Scrubs
Makeup Products
Soap
Shower Gels
Body Lotions
Others

Have you used any hair removal methods in the past six weeks?

Yes

Other skin conditions:

What areas of concern do you have regarding your: Eyes (Check all that apply)

Dehydrated

Wrinkles

Puffiness

Dark circles

Other eye conditions:

What areas of concern do you have regarding your: Lips (Check all that apply)

Dehydrated

Cracked/chapped lips

Other lip conditions:

If yes, please specify which and your reaction

What SPF do you use on your face?

Have you recently used any self-tanning lotions, creams or treatments?

If yes, please specify which product

Have you had any recent tanning bed or sun exposure that changed the color of your skin?

Yes

If yes, please specify where

How many glasses of water do you drink per day? (Please check one)

<1 glass

1-3 glasses

4-7 glasses

8+ glasses

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

How many alcoholic beverages do you consume per week? (Please check one)

I don't drink

1-3 drinks

4-7 drinks

8+ drinks

Do you exercise on a regular basis?

Yes

Do you smoke cigarettes, vape, or consume other tobacco products?

Yes

What are your stress levels on a scale from 1 to 5 (1 = low stress, 5 = high stress)?

Are you taking oral contraceptives?

Yes

If so, which contraceptive?

Any recent changes to or from your contraceptive treatments?

Yes

If yes, please specify what and when

Are you pregnant or trying to become pregnant?

Yes

Are you experiencing any menopausal symptoms?

Yes

If yes, please specify what kind

Are you undergoing any hormone replacement therapy treatments?

Yes

If yes, please specify the treatment

Do you experience irritation from shaving?

Yes

If yes, please specify the irritation

Do you experience ingrown hairs as a result of hair removal?

Yes

Future Appointments/Contact

May I call you at the provided phone number to confirm future appointments?

Yes

May I contact you via mail/email about future promotions and news?

Yes

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.

Client Name (Printed)

Client Signature

Clear