|
Your
Name |
|
|
Email Address |
|
|
Address |
|
|
Age Group |
|
| |
|
|
Your Health |
|
| |
|
|
Within the last year have you been under a Dermatologist or a
Physicians care?
|
|
Within the last nine months have you undergone any surgery?
|
|
Have you had any health problems in the past or present?
|
|
List any medications, supplements, diuretics, slimming tablets etc
that you take regular.
|
|
Do you smoke?
|
|
Do you exercise regularly?
|
|
Do you follow a restricted diet?
|
|
Do you wear contact lenses?
|
|
Do you have metal implants, a pacemaker or body piercing?
|
|
Rate your stress level on a scale of 1 to 4 ( 1= low stress 4= High
stress )
|
| |
|
|
Your Skin |
|
| |
|
|
Do you have any special skin problems pertaining to your face or
body? yes no
If yes please specify..
|
| |
|
|
What skin products do you currently use |
| |
|
|
Face |
|
| |
|
|
Soap |
|
|
Cleanser |
|
|
Toner |
|
|
Moisturizer |
|
|
Masque |
|
|
Exfoliator |
|
|
Eye Products |
|
| |
|
|
Body |
|
| |
|
|
Soap |
|
|
Shower Gel |
|
|
Scrubs |
|
|
Oil |
|
|
Body Moisturizer |
|
|
Depilatory Products |
|
|
Self Tanners |
|
| |
|
|
Exfoliation History |
|
| |
|
|
Have you ever had chemical peels, Microdermabrasion, or any
resurfacing treatments,
In the last month?
|
|
Do you use Accutane, Retin A, Renova, Adapelene or any other
prescription products?,
In the last 3 months?
|
Are you currently using any products that contain the following
ingredients?
|
|
Glycolic Acid |
|
|
Lactic Acid |
|
|
Any exfoliating scrubs |
|
|
Any Hydroxyl acid products |
|
|
Vitamin A derivatives |
|
| |
|
|
Moisture Hydration |
|
| |
|
|
How much plain water do you consume
daily? |
in Pints |
|
How many alcoholic beverages do you consume
weekly? |
in Pints |
|
Do you ever experience any of these conditions on your skin, i.e.
Flakiness,
Tightness or
Obvious dryness?
|
|
What sunscreen do you use on your
face or body |
|
|
Do you sunbathe or use tanning beds? |
|
| |
|
|
Capillary activity |
|
|
Do you burn easily in moderate sunlight? |
|
|
Do you blush easily when nervous? |
|
|
Do you have a tendency to redness? |
|
|
Do you suffer from sinus problems? |
|
| |
|
|
Oil secretion |
|
| |
|
|
Do you ever experience oily shine all through the day? |
|
|
Do you ever experience skin breakouts? |
|
| |
|
|
Nerve activity |
|
|
|
|
|
Do you drink more than 4 caffeinated beverages daily ( Coffee, tea,
soft drinks)?
|
|
Do you ever experience a burning itching sensation on your skin?
|
|
What is your pain threshold? |
|
|
Have you ever had claustrophobia? |
|
|
What type of massage do you prefer? |
|
| |
|
Have you ever had a reaction to any of the following?
|
|
cosmetics |
|
|
medicine |
|
|
iodine |
|
|
pollen |
|
|
food |
|
|
hydroxyl acids |
|
|
animals |
|
|
fragrance |
|
|
sunscreens |
|
|
other |
|
| |
|
|
Female clients only |
|
|
Are you taking oral contraception? |
|
|
Are you pregnant or trying to become pregnant? |
|
|
Are you lactating? |
|
| |
|
|
Male clients only |
|
|
What is your shaving system? |
|
|
Do you experience irritation from shaving? |
|
|
Do you experience ingrown hairs? |
|
| |
|
|
General Health questions |
|
|
Are you currently having or due for your menstrual period?
|
|
|
Have you started any new medication recently? |
|
|
Have you had any recent dental x-rays? |
|
|
What are your skin goals? |
|
| |
|