Date*

Month Day Year

Name*

First Name Last Name

Date of Birth*

*

Street Address

Barangay City

Province Country

Mobile Number*

Area Code Phone Number

E-mail*

example@example.com

Occupation*

How did you hear about us?*

If Referral, please list name

If Other, please let us know

What are your skin care goals?*

Acne Free Wrinkle Free Brighter Younger Looking

What are your skin care challenges?*

Please feel free to go into more detail

Have you ever had a facial or skin treatment before?*

Yes No

If Yes, when?

What Skin Care Products do you currently use?*

Please specify which product or type, if you answered 'Yes, currently using' to above.

If checked, please note last time.

Have you ever received chemical peels, laser services, or microdermabrasion treatments?*

Yes, within the last month Yes, within the last 2-3 months No

Have you experienced any of these health conditions in the past or present?*

If you checked YES to any of these please provide further information. If not mark, NA*

Do you?*

Do you take any of the following dietary / health supplements?

If other, please list

Any known allergies?*

If Other, please specify

Have you used or been prescribed any medications (topical or oral) for acne / acne control?*

Yes No

If yes, please specify what and date last used

Are you a smoker?*

Yes No Social

Do you drink more than 4 caffeinated beverages a day? (tea, coffee, soda, energy drinks)*

Yes No

Please rate your stress level*

Low Medium High

FEMALE CLIENTS

Are you taking birth control?*

Yes No N/A

If yes, what kind

Are you pregnant or trying to become pregnant?*

Yes No Recently had a baby and am breastfeeding N/A

When was your last period?*

Any menopause issues?*

Yes No N/A

If yes, please specify

Are you undergoing any hormone replacement therapy?

Yes No

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