New Client Consultation | SWFL SKIN | Bonita Springs, FL

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone *

Email *

Occupation *

Birthday *

Ethnicity *

Referred by *

Who can we thank with a gift for you coming in today?

Check the areas you would like to improve with your skin: *

Please indicate which services you are interested in: *

List the skincare products currently using *

Have they achieved the results you want? *

Do you wear sunscreen daily? *

Is your skin… *

Oily or Acne Prone
Dry
Normal
Sensitive/Reactive

Medical History

Do you smoke? *

Are you currently, or have you ever experienced any of the following: *

If you are currently experiencing or being treated for any health-related condition, please describe

Have you had plastic surgery *

If yes, what was the date of the surgery?

If yes, what was the description of the surgery

Are you currently using Retin-A, Retinol, AHA or any peeling agent? *

If so, how long?

If so, strength?

If so, how have your results been?

Do you suffer from claustrophobia or anxiety? *

Do you have any allergies? Also list any skin treatment products you have used that caused an unexpected reaction or side-effect *

Do you have tendency to keloid scar? *

Have you had a skin peel in past 2 years? *

Results

Brand

Please indicate if you have ever used any of the following medications for skin treatment: *

When was the last time you used these medications

Women

Are you pregnant *

Are you planning to become pregnant in the near future *

Are you currently on any type of hormone therapy *

If so please describe

Do you have normal periods *

Are you going through menopause *

Do you have any hormone imbalance *

Have you undergone surgical menopause therapy (hysterectomy) *

Lifesyle and Stress Analysis

Do you come into contact with any chemicals at work? *

If so please list

Do you work around excessive heat or cold *

Use hot tubs or saunas *

How often do you exercise *

Average hours of sleep *

Average current stress level on a 1-10 scale (1 being least and 10 being most) *

How many minutes on average a day are you exposed to the sun (driving in a car counts) *

Do you use a tanning bed? *

If so how often

Do you experience cold sores *

Please check any that apply to your eating habits (zero judgement zone here! It can help identify skin tendencies)

How much water do you drink a day *

How much caffeine do you consume a day *

Carbonated drinks per day *

Average alcohol consumption per week *

Have you changed the brand of skincare you use within the last year *

If yes, why did you change

Have you been under a physicians care during the past 3 years *

Are you currently taking any medication *

If yes, please list the medication name and how long you have been taking that medication

Are you currently taking any vitamins or supplements *

If yes, please list the name and how long you have been taking it

Feel free to use this space to let the aesthetician know anything you think would be helpful to know before your appointment to best help them come up with the best treatment plan for you

Signature *

How did you about BellJax? *