Skincare History Questionnaire and Waiver Form

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Skincare History Questionnaire and Waiver

Health History

Please answer the following questions so that your Skincare Specialist may have a better understanding of your general health and lifestyle, thereby enabling your Skincare Specialist to accurately analyze and assess your skincare needs.
Name:*
Today’s date:*
Date Format: MM slash DD slash YYYY
Address*
City:*
City
State:*
State
Zip code:*
ZIP
Cell Phone :*
Date of Birth:*
Date Format: MM slash DD slash YYYY
Age:*
Email Address:*
How did you hear about our office?*

Allergies:

Have you ever had an allergic reaction to any of the following:
ASPIRIN OR SALICYLATES
- Yes
- No
MILK
- Yes
- No
APPLES
- Yes
- No
CITRUS
- Yes
- No
INGREDIENTS IN SKINCARE PRODUCTS
- Yes
- No
LATEX
- Yes
- No
FISH, MARINE OR IODINE ALLERGIES
- Yes
- No
GRAPES
- Yes
- No
If checked yes to any of the above, please explain:
Please list any other known allergies:
Have you ever had Herpes Simplex?
- Yes
- No
Are you being treated for Hepatitis?
- Yes
- No
Female clients only:
Are you on hormone replacement therapy?
- Yes
- No
Are you presently taking birth control pills?
- Yes
- No
Are you pregnant or nursing?
- Yes
- No
Skincare History
Are you currently having skin treatments?
- Yes
- No
Please check if you are presently using or have used in the past any of the following:
Benzoyl Peroxide (BPO)
- Yes
- No
Glycolic Acid (AHA)
- Yes
- No
Lactic Acid (AHA)
- Yes
- No
Resorcinol
- Yes
- No
Salicylic Acid (BHA)
- Yes
- No

PRESCRIPTION PRODUCTS:
Tretinoin (Retin A, Retin-A Micro®, Renova, Avita)
- Yes
- No
Adepalene (Differin®)
- Yes
- No
Azelaic Acid (Azelex®, Finacea™)
- Yes
- No
Tazarotene (Tazorac®)
- Yes
- No
Isotretinoin (Accutane)
- Yes
- No
Triluma™
- Yes
- No
Metrogel
- Yes
- No
Other
- Yes
- No
PLEASE CHECK IF YOU ARE PRESENTLY EXPERIENCING OR HAVE EXPERIENCED ANY OF THE FOLLOWING:
Skin Cancer
- Yes
- No
Dermatitis
- Yes
- No
Keloid Scarring
- Yes
- No
Acne
- Yes
- No
Rosacea
- Yes
- No
Broken Capillaries
- Yes
- No
Treatment Reactions
- Yes
- No
Hypopigmentation
- Yes
- No
Hyperpigmentation
- Yes
- No

SUN PROTECTION:
Do you use a sunscreen?
- Yes
- No
Do you sunbathe or participate in outdoor activities?
- Yes
- No
Do you tan in a tanning booth?
- Yes
- No
Have you tanned in a tanning booth in the last 14 days?
- Yes
- No
Have you had any direct sun exposure in the last 10 days?
- Yes
- No
WHEN EXPOSED TO THE SUN DO YOU:
- Always burn, never tan
- Always burn, sometimes tan
- Sometimes burn, sometimes tan
- Always tan
Do you feel your skin is sensitive?
- Yes
- No
WHAT SKIN CONDITIONS DO YOU WANT TO IMPROVE?
Acne and/or breakouts
- Yes
- No
Facial Scarring
- Yes
- No
Hyperpigmentation (freckles, age spots)
- Yes
- No
Hypopigmentation
- Yes
- No
Enlarged Pores
- Yes
- No
Fine Lines and Wrinkles
- Yes
- No
Other
- Yes
- No
Is there any other necessary information your Skincare Specialist should know before beginning your treatment?
- Yes
- No
*
- I have acknowledged that all the information provided by me is true and correct to the best of my knowledge. I understand that some skin conditions may require more than one treatment and homecare products to achieve the result desired. Results cannot be guaranteed due to individual skin type(s) and condition(s). I understand I need to sign this waiver prior to every treatment provided, with ANY changes pertaining to the above questionnaire.

Skincare History Questionnaire and Waiver