Facial Treatment - Client Intake Form

Client Intake Form

Facial Service
Name

First NameLast Name
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Your Health

Please answer all questions truthfully and to the best of your knowledge
Within the last year, have you been under a dermatologist’s or other physician’s care?*

YesNo
If yes, please specify:
Have you had any health problems in the past or present?*

YesNo
If yes, please specify:
Do you have any allergies?*

YesNo
If yes, please specify:
Check if you are allergic to:

sulfuraspirin
List any medications, supplements, vitamins, diuretics, slimming pills, Accutane, etc that you take regularly?*
If you had used Accutane, provide the date of last time you took it.

MonthDayYear
Date
Do you smoke?*

YesNo
Do you exercise regularly?*

YesNo
Do you follow a restricted diet?*

YesNo
Do you have metal implants, a pacemaker or body piercings?*

YesNo
Do you wear contact lenses?*

YesNo
Do you sunbathe or use tanning beds?*

YesNo
Do you drink more than 4 caffeinated beverages daily (coffee, tea, soft drinks)?*

YesNo
Have you ever experienced claustrophobia?*

YesNo
Rate your stress level on a scale of 1 to 5*

1

2

3

4

5

1 is Low, 5 is High
Your Skin
What are your specific concerns / challenges with your skin?*
What skin care products are you currently using on your face? Please check all that apply.*

SoapCleanserTonerMoisturizerMasqueExfoliatorEye ProductsNone
What skin care products are you currently using on your body? Please check all that apply.*

SoapShower gelScrubsOilsHair remover productsSelf tannersNone
Have you ever had chemical peels, microdermabrasions, or any resurfacing treatments?*

YesNo
If yes, in the last month?
Do you use Retin-A, Renova, Adapalene or any other prescription skin products?*

YesNo
If yes, in the last month?
Are you currently using any products that contain the following ingredients?*

Glycolic acidLactic acidExfoliating scrubsHydroxy acid productsVitamin A derivatives (ie., Retinol)None
Have you ever experienced the following conditions on your skin?*

FlakinessTightnessObvious drynessNone
What SPF sunscreen do you use on your face? (specify brand)
What SPF sunscreen do you use on your body? (specify brand)
Do you burn easily in moderate sunlight?*

YesNo
Do you suffer from sinus problems?*

YesNo
Do you ever experience burning, itching or stinging sensations on your skin?*

YesNo
Do you have a tendency to redness?*

YesNo
Female Clients Only
Are you taking oral contraception?*

YesNo
Are you pregnant?*

YesNo
Are you lactating?*

YesNo
Are you currently having or due for a menstrual cycle?*

YesNo
Male Clients Only
Do you have shaving challenges?*

YesNo
If yes, please specify:
Questions to discuss every visit
Have you started any new medications since your last visit?

YesNo
If yes, please specify:
*Confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment.*

Clear
Should be Empty:

Client Intake Form

Your Health

Your Skin

Female Clients Only

Male Clients Only

Questions to discuss every visit