Client Intake Questionnaire Please complete this form at least 2-3 days before your scheduled service appointment! Client Name *FirstLastEmail *Phone *Cell Provider *Date of Birth (MM/DD/YYYY)How did you hear about us? *Medical HistoryDo you have any of the following medical conditions? Please check box. *Blood Clotting AbnormalitiesCancerDiabetesEpilepsyHepatitisHerpes Virus/ Cold SoresHigh Blood PressureHIVHormone ImbalanceHysterectomyKeloid ScarringSeizuresSkin DiseaseThyroid Imbalance None of thesePlease list any other heath problems or medical conditions? *List any Prescription drugs (topical or internal) *Examples: Retin-A, Accutane (last yr), Antibiotics, Cigarettes, Stimulants, Diuretics, Oral ContraceptivesHave you used Retin-A in the last week? *YesNoHave you had cosmetics surgery? *YesNoExample: Laser, Botox, Fillers, Face Lift, etc.If yes, please list it here: *Laser, Botox, Fillers, Face Lift, etc.FEMALE CLIENTS: Are you pregnant? *YesNoDoesn't apply to me!LifestyleOccupation:What is your stress level (1-5) *1 (low to no stress)2345 (high stress)Do you exercise? *YesNoList all the supplements and mg you take per day?Daily intake of Water in ounces? *How many cups of Coffee? How do you take it? *How many cups of Tea? Sweet, Unsweet, Herbal, or Black? *Soda? *Alcohol: Drinks per week? *Your Skin & ExperiencesSkin Condition: *DryOilyFlakingTighteningOtherIf selected other, please describe here:Do you experience skin breakouts? *Yes, frequentlyNoSometimesSkin Care RoutineSkin Care Routine: *CleanseToneExfoliateMoisturizer Eye CreamNight CreamMaskSPFNoneFrom the above list, please list all of the products you use for your Skin Care Routine *For Example, Cleanse: Olay cleanser Tone: Seabreaze Exfoliate: Almond scrub.Allergies (food/ other): *Have you ever had a reaction to any skincare treatments before? *If yes, please describe treatment and reaction.What are your skincare goals? *Signature *Clear SignatureBy signing you agree that all information you have provided here is true and correct.SignatureClear SignatureOffice Use Only. Medical Director SignaturePhoneSubmit
