Questionnaire for facial treatments

Book your appointment with us and fill in the online consultation form to be ready for your session.

Name

Date

Email Address

Contact Number

Your Health

1) Within the last year, have you been under a dermatologist’s care?YesNo

If yes, please specify

2) Have you had any health problems in the past year?YesNo

3) List any medications, supplements, vitamins, diuretics, slimming pills, lsotretinoin, etc. that you take regularly?

4) Do you smoke?YesNo

5) Do you exercise regularly?YesNo

6) Do you follow a restricted diet?YesNo

7) Do you wear contact lenses?YesNo

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

9) Rate your level of stress on a scale of 1 to 5 (1= low stress, 5 = high stress)

10) Do you have any allergies? Latex, Nickel, etc.?YesNo

If yes, please specify

11) Have you ever had an allergic reaction to Aspirin?YesNo

12) Do you sunbathe or use tanning beds?YesNo

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

14) Have you ever experienced claustrophobia?YesNo

Your Skin

15) What are your specific concerns or challenges with your skin

16) What skin products are you currently using?

For your FaceFaceSoapCleanserTonerMoisturizerMasqueExfoliatorEyeTreatmentSerums

For your SkinSoapShower GelScrubsOilBody MoisturizerDepilatory ProductsSelf - Tanner

17) Have you had a chemical peel, microdermabrasion, laser, or light therapy, an injectable, or other cosmetic procedure in the last month?YesNo

18) Have you waxed in the last 72 hours?YesNo

19) Have you used in the last 3 months Retin-A, Renova, Adapalene, or any other prescription skin products?YesNo

20) Have you taken isotretinoin (Accutane) within the last 6 – 12 months?YesNo

21) Are you currently using any products that contain the following ingredients?Glycolid AcidLactic AcidAny Exfoliating ScrubsHydroxy AcidVitamin A Derivatives (Retinol)

22) Do you ever experience these conditions on your skin?FlakinessTightnessObvious Dryness

23) What SPF sunscreen do you use on your face?

23) What SPF sunscreen do you use on your body?

24) Do you burn easily in moderate sunlight?YesNo

25) Have you had any direct sun exposure within the last 48 hours?YesNo

26) Do you have a tendency to redness?YesNo

27) Do you suffer from sinus problems?YesNo

28) Are you prone to cold sores or fever blisters?YesNo

29) Are you currently experiencing a break out?YesNo

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

29) Are you currently experiencing a break out?YesNo

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

If yes please specify

Female Clients Only:

31) Are you taking oral contraception (birth control)?YesNo

32) Are you pregnant or trying to become pregnant?YesNo

33) Are you lactating?YesNo

34) Are you currently having or due for your menstrual period?YesNo

35) Do you have any shaving challenges?YesNo

Male Clients Only:

35) Do you have any shaving challenges?YesNo

If yes please specify

Questions To Discuss Every Visit

36) Have you started any new medications since your last visit?YesNo

If yes please specify

37) What are your expectations with this treatment and today’s visit

Confirmation *I confirm that (to the best of my knowledge) that the answers I have provided are correct and that I have not withheld any information that may be relevant to my treatment.Confirm

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