fACIAL iNTAKE fORMPlease fill out our intake form to prepare your esthetician for your services! Looking forward to seeing you! Name * First Name Last Name Date * MM DD YYYY Birthdate * MM DD YYYY Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Emergency Contact * First Name Last Name Phone * (###) ### #### What services are you interested in? Skin Care Consultation/Advice Home Care Products Clinical Treatments Age Managment Acne Treatment/Managment Rosacea What do you wish to change about your skin? Acne Blackheads/Whiteheads Broken Capillaries Discoloration Dryness Dull Skin Fine Lines/Wrinkles Eczema Hyperpigmentation Hypopigmentation Milia Oily Skin Redness Rosacea Scarring Sensitivity Sun Damage Thin Skin Unwanted Hair Other If you selected other, please list. * Medical History Are you currently, or have your previously experienced any of the following: Heart Condition Thyroid Condition Pacemaker Metal Implants Headaches or Migraines Anemia High Blood Pressure Low Blood Pressure Cancer Kidney Problems Diabetes Arthritis Hemophilia Asthma Hypo/Hyper gylcemia Hepatitis Herpes Simplex AIDS/HIV Positive Autoimmune Dermatitis Acne Eczema Easily Bruised/Sensitive Skin Fungal Condition Depression Epilepsy/Seizures Loss of Sensation Blood Clots Varicose Veins Fatigue Insomnia Contact Lenses If you are currently experiencing or being treated for any health-related condition, please discribe: * Have you ever had a surgical or non-surgical procedure? If yes, where on your body was the surgery performed? * Do you have any allergies? Also list any skin treatment products or ingredients you have used that caused an unexpected reaction or side-effect: * Please list all over the counter and prescription medications you are currently taking: Please indicate if you have ever used any of the following medication for skin treatment: Accutane Cortisone Staticin Benzoyl Peroxide Retin A Sulfer Desquam X Zerac Fosdex Glycolic Acid Salicylic Adic Lactic Acid Renova Clindamycin Tazoratene Metrogel What condition were you treating with this medication(s)? When was the last time you used these medications? Are you pregnant? Yes No Are you planning a pregnancy in the near future? Yes No Are you currently breastfeeding? Yes No Are you currently on any type of hormone therapy? If yes please discribe: Do you have regular periods? Yes No Do you have any hormone imbalance? Yes No Are you going through menopause? Yes No Have you undergone surgical menopause (hysterectomy)? If yes, when? What skin care products are you currently using? (AM & PM) Are you wearing daily sunscreen? If yes, what Type & SPF? Is your skin: Oily Acne prone Dry Normal Sensitive Have you ever treated or been treated for a skin condition? If yes, what condition? How did you treat the condition? Dermatologist Aesthetician Self-treated with drug store products Self-treated with department store products Were you happy with the results? * Yes No Are you currently treating or being treated for any skin condition? Yes No Do you come in contact with chemicals at work? Do you work around excessive heat or cold? Do you use Personal Protective Equipment (PPE*)? If so, what type and for how long? *masks, gloves, shields, ect. How often do you exercise? Average hours of sleep? What is your stress level? How many minutes a day are you exposed to sunlight? How many hours a week do you use a tanning bed? Do you get cold sores? Yes No Please indicate any of the following that apply to your eating habbits: Fast Food Baked Bread Salt Seafood Dairy Products Ethnic or Spicy Foods Peanut Butter Peanuts How much water do you drink per day? How much caffeine do you intake per day? How many carbonated drinks do you have per day? Do you smoke tobacco products? Yes No Average alcohol consumption per week? Have you changed your brand of skincare products in the last year? If yes, why did you change? Are you currently? (Check if Yes) IT IS NOT RECOMMENDED THAT YOU GET THIS SERVICE IF ANY OF THESE APPLY Sunburned, windburned, have irritated or broken skin Have any open wounds or active cold sores/fever blisters Within the last 2 days? (Check if Yes) IT IS NOT RECOMMENDED THAT YOU GET THIS SERVICE IF ANY OF THESE APPLY Had a facial Had laser hair removal/electrolysis on the treatment area Had any facial waxing Within 1 week? (Check if Yes) IT IS NOT RECOMMENDED THAT YOU GET THIS SERVICE IF ANY OF THESE APPLY Used a topical and/or oral prescription strength medication (such as Retin A) Had microdermabrasion/ Microderm infusion Had Botox, injectables and/or derma fillers Had dermaplaning Within 2 weeks? (Check if Yes) IT IS NOT RECOMMENDED THAT YOU GET THIS SERVICE IF ANY OF THESE APPLY Had eyebrow microblading Had a chemical peel or another exfoliation treatment Had microneedling done Within 1 month? (Check if Yes) IT IS NOT RECOMMENDED THAT YOU GET THIS SERVICE IF ANY OF THESE APPLY Had Intense Pulsed Lighting and/or Photofacial Within 6 months? (Check if Yes) IT IS NOT RECOMMENDED THAT YOU GET THIS SERVICE IF ANY OF THESE APPLY Taken accutane Had radiation Had chemotherapy Had any form of laser treatment and/or cosmetic surgery Thank you!
