elevatemindskinsoul.com - SKIN CARE HISTORY QUESTIONNAIRE

SKIN CARE HISTORY QUESTIONNAIRE
Please answer the following questions so that I may have a better understanding of your general health and lifestyle, thereby enabling me to accurately and anlyze and assess your skin care needs.
Name

First NameLast Name
Date

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Email Address
example@example.com
Please check if presently using any of the following? (Please check all that apply)

AccutaneHydroquinoneGlycolic Acid/Alpha Hydroxy AcidAny prescription strength topical i.e. steroids, Retin-A, Tazorac, Differin, etc.
Which conditions do you want to improve? (Please check all that apply)

Hyperpigmentation (Brown Spots)Acne/Acne ScarringSun DamageEnlarged PoresFine Lines & WrinklesAge SpotsSurgical Facial ScarsOther
Have you ever had an allergic reaction to any skin product or cosmetic?

YesNo
FEMALE CLIENTS
Are you on hormone replacement therapy?

YesNo
Are you presently taking birth control pills?

YesNo
Are you pregnant or planning to be?

YesNo
ALL CLIENTS
Do you use a sunscreen/sun block?

YesNo
Do you sunbathe or participate in indoor activities ?

YesNo
Do you have or have ever had acne?

YesNo
Are you using or have ever used any medications for acne?

YesNo
Name of medication:
Have you seen a Dermatologist in the past year?

YesNo
If yes, list doctors name and reason for visit
Are you presently under a doctor's care?

YesNo
What medications do you take on a regular basis?
Have you ever had Herpes (cold sores)?

YesNo
Have you ever been treated with Zovirax or any medication for Herpes?

YesNo
Do you have Epilepsy, Diabetes, or other auto auto-immune disorders ?

YesNo
If yes, you will be treated with only a doctors release!
Are you presently under a physicians care for any reasons?

YesNo
Explain:
Do you use Biore or snore strips?

YesNo
Have you had any of the following? ( Please check all that apply)

Cosmetic SurgeryBotox InjectionsSkin CancerDermatitisKeloid ScarringLaser Resurfacing/IPLChemical PeelsHepatitisDermal FillersOther ( Specify)
Are you allergic to aspirin?

YesNo
Are you allergic to Iodine or Seaweed?

YesNo
Do you have any other allergies?

YesNo
If yes, list:
Do you smoke?

YesNo
Do you take nutritional supplements?

YesNo
Are you on a diet?

YesNo
Do you exercise?

YesNo
Do you wear contact lenses?

YesNo
Have you had skin treatments(facials) before?

YesNo
Are you currently having facials?

YesNo
Have you had electrolysis or waxing in the past week?

YesNo
Do you have those services done?

YesNo
Have you had permanent cosmetics?

YesNo
If yes, where?
How is your general health?

ExcellentGoodFairPoor
What skin care products are you currently using?
What is it about your skin you would like to change?
Is there any other information I should know before beginning your treatment?
Client Signature

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SKIN CARE HISTORY QUESTIONNAIRE

FEMALE CLIENTS

ALL CLIENTS