Your Information

First Name

Last Name

Date of birth

Ethnicity

Address

City

State

Postal code

Phone *

Cell Phone

Email *

Medications

Indicate When & How Long

Antibiotics

Accutane

Benzoyl Peroxide

Retin A

Cream or Gel?

Tazorac

Differin

Azelex

Avita

Cleocin-T

E-mycin-T

Copaxone

Corticosteroids

Quinine

Other Meds

Androstendione

Testosterone

Progesterone

Thyroid

Gonadotrophin

Danzol

Cyclosporin

Lithium

Isoniazid

Immuran

Disulfuram

Dilantin/Tegretol

Steroids

Marijuana

Cocaine/Speed

Medical History

Lifestyle Considerations

Your Primary Care Physician:

Are you under a dermatologist’s or other physician’s care?

Have you ever had any reaction to any products or anything you have put on your face?

Yes

If yes, what products?

Please check any of these you are allergic to:

Sulfur

Aspirin

Latex

List any other allergies you know of:

Do you smoke?

Yes

Do you use fabric softener or fabric softener sheets in the dryer?

Yes

Do you swim in a chlorinated pool?

Yes

Do you work around chemicals, tars, oils, grease or inks?

Yes

Occupation

Do you work nights?

Yes

Are you currently under a lot of stress? (common stress = job loss, new job, wedding, romantic breakup, death in the family or close friend, graduation, difficult home life, long commute, heavily scheduled)

Yes

Women: Do you use birth control pills, shots or use an IUD?

Yes

With birth control, which do you use? (if pill, which brand?)

Are you pregnant or nursing?

Yes

Men: Do you have shaving irritation?

Yes

What type of razor do you use for shaving?

If any of the above, which one and how often per week?

Products Currently Using - Please Provide Product Names

Cleanser
Toner
Serums
Moisturizers
Sunscreen
Mask
Foundation
Blush
Exfoliant (acids, serums, scrubs)
Acne Medications
Anything Else?

Other Treatments: What else have you done for your skin in the last 90 days?

Treatment
Chemical Peels
If so, what kind?
Microdermabrasion
Dermabrasion
Laser Hair Removal
Laser Rejuvenation/Resurfacing
Skin Cancer Removal
Facial Waxing
Electrolysis
Other:

How did you hear about us?

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

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