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.

Have you seen a dermatologist in the past year?

Are you presently under a physician’s care?

Are you currently taking any medications?

How is your general health?

Please rate your stress level

Please select the following conditions you have or had experienced:

hypertension

lupus

heart attack

stroke

metal plate

irregular pulse

epilepsy

contact lenses

diabetes

claustrophobia

headaches

anemia

fainting

cancer

asthma

varicose veins

cold sores

thyroid disorders

hepatitis

seizures

hernia

high cholesterol

tooth fillings

eating disorder

high/low blood pressure

autoimmune disorder

Do you take nutritional supplements?

Do you exercise?

Do you have a tendency to scar?

Allergies:

Have you ever had an allergic reaction to any of the following:

ASPIRIN OR SALICYLATES

MILK

APPLES

CITRUS

INGREDIENTS IN SKINCARE PRODUCTS

LATEX

FISH, MARINE OR IODINE ALLERGIES

GRAPES

Have you ever had Herpes Simplex?

have you ever been treated with Denavir® (Penciclovir), Zovirax® (Acyclivor) or Abreva?

Are you being treated for Hepatitis?

Female clients only:

Are you on hormone replacement therapy?

Are you presently taking birth control pills?

Are you pregnant or nursing?

Skincare History

Are you currently having skin treatments?

Please check if you are presently using or have used in the past any of the following:

Benzoyl Peroxide (BPO)

Glycolic Acid (AHA)

Lactic Acid (AHA)

Resorcinol

Salicylic Acid (BHA)

Do you have or have you had any of the following in the last 14 days?

Facial Cosmetic Surgery

Botox Injections

Collagen Injections

Fillers

Light Treatments

Laser Resurfacing

Microdermabrasion

Other

HOMECARE:

What Skincare products are you currently using at home?

PRESCRIPTION PRODUCTS:

Tretinoin (Retin A, Retin-A Micro®, Renova, Avita)

Adepalene (Differin®)

Azelaic Acid (Azelex®, Finacea™)

Tazarotene (Tazorac®)

Isotretinoin (Accutane)

Triluma™

Metrogel

Other

PLEASE CHECK IF YOU ARE PRESENTLY EXPERIENCING OR HAVE EXPERIENCED ANY OF THE FOLLOWING:

Skin Cancer

Dermatitis

Keloid Scarring

Acne

Rosacea

Broken Capillaries

Treatment Reactions

Hypopigmentation

Hyperpigmentation

SUN PROTECTION:

Do you use a sunscreen?

Do you sunbathe or participate in outdoor activities?

Do you tan in a tanning booth?

Have you tanned in a tanning booth in the last 14 days?

Have you had any direct sun exposure in the last 10 days?

WHEN EXPOSED TO THE SUN DO YOU:

Do you feel your skin is sensitive?

WHAT SKIN CONDITIONS DO YOU WANT TO IMPROVE?

Acne and/or breakouts

Facial Scarring

Hyperpigmentation (freckles, age spots)

Hypopigmentation

Enlarged Pores

Fine Lines and Wrinkles

Other

Is there any other necessary information your Skincare Specialist should know before beginning your treatment?