Confidential Skin Health Questionaire

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CONFIDENTIAL SKIN HEALTH QUESTIONNAIRE
Today’s Date__________________________ Date Of Birth____________________
Full
Name_______________________________________________________________
Address______________________________________________________________
Cell_______________________________Work______________________________
Your Occupation_______________________________________________________
E-mail_______________________________________________________________
Referred by___________________________________________________________
Reason for your visit today?______________________________________________
What areas of your skin would you like to improve?________________________________________________________________
__________________________________________________________________________________________________________
Have you ever had a facial treatment? And what was your experience?________________________________________________
Would you describe your skin? Normal______ Dry______
Oily______ Combination_______ Sensitive______
Sun Damaged______
How would you rate your skin? Circle the one that best describes your skin.
1 Always burns
2. Burns easily, tans slightly
4. Seldom burns, always tans well
3. Burns moderatly, tans gradually
5.Rarely burns, deep tan
6.Never burns, deeply pigmented
What is your present skin regimen?_____________________________________________________________________________
Do you blush easily?________________ If yes what are the contibuting factors?_________________________________________
Do you sun bathe or use a tanning bed? If yes how often?___________________________________________________________
Have you ever had any Chemical Peels, Microdermabrasion, Facial Surgery, Botox, Laser Resurfacing or Collagen Injections? If yes
When?____________________________________________________________________________________________________
Does your skin heal:
Fast________
Scars________
Pigments________
Do you get cold sores? If yes how often?________________________________________________________________________
What Medications/ Hormone replacement/ Vitamins do you presently take?____________________________________________
__________________________________________________________________________________________________________
Have you ever used Accutane, Retin-A, Renova, Differin, Tazarac, Alpha Hydroxy Acids or Hydroquinone? If yes what, when and
for how long?_______________________________________________________________________________________________
Any family history of skin cancer?_______________________________________________________________________________
Please list any allergies you may have____________________________________________________________________
__________________________________________________________________________________________________
Are you pregnant? Or breast feeding?___________________________________________________________________
Have you ever had any of the following, past or present?
Acne
Yes_____
No____
When_______________________________________________
Blood Pressure
High____
Low____
Normal________
Cancer
Yes_____
No____
Diabetes
Yes_____
No____
Eczema
Yes_____
No____
STD’s
Yes_____
No____
Hepatitis
Yes_____
No____
HIV/AIDS
Yes_____
No____
Do you smoke?
Yes_____
No____
If yes when and what?__________________________________
In our treatment program, it may be necessary to recommend alterations to or additions in your home care regimen; would that
be okay with you? Yes______
No_______
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
Aesthetician will completely inform me of what to expect in the course of treatment and will recommend adjustments to my
regimen if deemed necessary. I also am aware that individual results are dependent upon my age, skin conditions 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
obtain maximum effectiveness. In the event that I may have additional questions or concerns regarding my treatment or
suggested home product routine, I will consult with my Aesthetician immediately.
I release and hold harmless the Aesthetician, Karen Braun, Warm Springs Day Spa, and the staff from any liability for adverse
reactions that may result from this treatment.
I have read and understood all of the foregoing information
_______________________________________________________
_________________________
signature
Date