FACIAL INTAKE FORM

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What is your gender?
Does your job require you to work outdoors?

YOUR SKIN CARE

Have you ever had a facial treatment before?
Have you ever had a body spa treatment before?
If yes, please specify when and what treatment:
Do you have any special skin problems or concerns pertaining to your face or body?
What is your age range?
Have you ever had chemicals peels, laser treatments, or microdermabrasion in the last month?
Do you use Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/vitamin A derivative products?
Have you used acne medication?
Have you experienced Botox, Restylane, or collagen injections?
What skin care products are you currently using?
Have you used any hair removal methods in the past six weeks?
What areas of concern do you have regarding your: Skin (Check all that apply)
Eyes (Check all that apply)
Lips (Check all the apply)
Have you ever had an allergic reaction to any of the following (Check all that apply)
Have you recently used any self-tanning lotions, creams or treatments?
Have you had any recent tanning bed or sun exposure that changed the color of your skin?

LIFESTYLE

How many glasses of water do you drink per day? (Please check one)
How many caffeinated beverages (coffee, tea, soda, etc.) do you consume per day? (Please check one)
How many alcoholic beverages do you consume per week? (Please check one)
How many hours of sleep do you get per night? (Please check one)
Which foods do you consume on a regular basis?
What does your daily commute look like?
How often do you travel on a plane?
How many hours do you spend in front of a screen or digital device?
Do you exercise on a regular basis?
Do you smoke cigarettes, vape, or consume other tobacco products?
What are your stress levels on a scale from 1 to 5 (1 = low stress, 5 = high stress)?

FEMALE CLIENTS

Are you taking oral contraceptives?
Any recent changes to or from your contraceptive treatments?
Are you pregnant or trying to become pregnant?
Are you experiencing any menopausal symptoms?
Are you undergoing any hormone replacement therapy treatments?

MALE CLIENTS

Do you experience irritation from shaving?
Do you experience ingrown hairs as a result of hair removal?
May I call you at the provided phone number to confirm future appointments?
May I contact you via mail/email about future promotions and news?

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.

Thanks for submitting!