Cell Phone *
Email *
Occupation *
List the skincare products currently using *
Have they achieved the results you want? * Yes Yes No
Do you wear sunscreen daily? * Yes Yes No
Do you smoke? * Yes Yes No
If you are currently experiencing or being treated for any health-related condition, please describe
Have you had plastic surgery * Yes Yes No
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? * Yes Yes No
If so, how long?
If so, strength?
If so, how have your results been?
Do you suffer from claustrophobia or anxiety? * Yes Yes No
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? * Yes Yes No
Have you had a skin peel in past 2 years? * Yes Yes No
Results
Brand
When was the last time you used these medications
Are you pregnant * Yes Yes No
Are you planning to become pregnant in the near future * Yes Yes No
Are you currently on any type of hormone therapy * Yes Yes No
If so please describe
Do you have normal periods * Yes Yes No
Are you going through menopause * Yes Yes No
Do you have any hormone imbalance * Yes Yes No
Have you undergone surgical menopause therapy (hysterectomy) * Yes Yes No
Do you come into contact with any chemicals at work? * Yes Yes No
If so please list
Do you work around excessive heat or cold * Yes Yes No
Use hot tubs or saunas * Yes Yes No
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? * Yes Yes No
If so how often
Do you experience cold sores * Yes Yes No
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 * Yes Yes No
If yes, why did you change
Have you been under a physicians care during the past 3 years * Yes Yes No
Are you currently taking any medication * Yes Yes No
If yes, please list the medication name and how long you have been taking that medication
Are you currently taking any vitamins or supplements * Yes Yes No
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
