Skin Questionnaire We can’t wait to have you in the studio! please fill out this questionnaire at least 48 hours before your skin consultation. CONTACT INFO Name * First Name Last Name Email * Phone * CLIENT HEALTH and DIET Age * Are you in Good Health? * Yes No Please List Any Medications You Are Currently Taking * Please List Any Allergies * Please List Any Vitamins, Herbs, Or Supplements You Take Regularly * Does Your Diet Include Any Of The Following? * Dairy Peanuts Wheat Fruit Soy Sugar No, my diet does not include any of the above. Daily Intake Of Water (Cups) * Daily Intake Of Coffee (Cups) * Daily Intake Of Tea (Cups) * Daily Intake Of Soda (Cans) * How Often Do You Drink Alcohol? * Do You Use Tobacco Products? * Yes No Are You Pregnant, Trying to Become Pregnant, Or Lactating? * Yes No SKIN HEALTH What Best Describes Your Facial Condition? * Oily Dry Sensative Normal I don't know Which Of The Following Would You Like To Improve? * Acne Enlarged Pores Blackheads Wrinkles/Signs Of Aging Pigmentation Issues Clogged Pores Rosacea Scarring Do You Currently Use Any Of The Following On Your Face? * Chemical Peels Scrubs Laser/IPL Microdermabrasion Facial Buffer RetinA (Prescription Vit A, Tretinoin) Glycolic Acid Benzoyl Peroxide Salicylic Acid None Of The Above Please List Products And Brands Of Skincare Are You Currently Using Do You Sunburn Easily? * Yes No Do You Tan Easily? * Yes No Do You Use A Tanning Bed? * Yes No Do You Have Any Active Facial Skin Cancer? * Yes No Details And/Or Adverse Reactions If Applicable To The Above Question What Are Your Long Term Skin Care Goals? * Is There Anything Else I Should Know? Thank you!
