Skincare History Questionnaire and Waiver Form -

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:

Date:

Address:

City:

State:

Zip code:

Cell Phone:

Date of Birth:

Age:

E-mail address:

How did you hear about our office?

Have you seen a dermatologist in the past year? YesNo

list dermatologist’s name, contact info and reason for visit:

Are you presently under a physician’s care? YesNo

list physician’s name and reason for visit:

Are you currently taking any medications? YesNo

list please:

What is your genetic background?

How is your general health? ExcellentGoodFairPoor

Please select the following conditions you have or had experienced:

hypertension YesNo

lupus YesNo

heart attack YesNo

stroke YesNo

metal plate YesNo

irregular pulse YesNo

epilepsy YesNo

contact lenses YesNo

diabetes YesNo

claustrophobia YesNo

headaches YesNo

anemia YesNo

fainting YesNo

cancer YesNo

asthma YesNo

varicose veins YesNo

cold sores YesNo

thyroid disorders YesNo

hepatitis YesNo

seizures YesNo

hernia YesNo

high cholesterol YesNo

tooth fillings YesNo

eating disorder YesNo

high/low blood pressure YesNo

autoimmune disorder YesNo

Do you take nutritional supplements? YesNo

Do you exercise? YesNo

Do you have a tendency to scar? YesNo

Allergies:

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

ASPIRIN OR SALICYLATES YesNo

MILK YesNo

APPLES YesNo

CITRUS YesNo

INGREDIENTS IN SKINCARE PRODUCTS YesNo

LATEX YesNo

FISH, MARINE OR IODINE ALLERGIES YesNo

GRAPES YesNo

If checked yes to any of the above, please explain:

Please list any other known allergies:

Have you ever had Herpes Simplex? YesNo

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

Are you being treated for Hepatitis? YesNo

Female clients only:

Are you on hormone replacement therapy? YesNo

Are you presently taking birth control pills? YesNo

Are you pregnant or nursing? YesNo

Skincare History

Are you currently having skin treatments? YesNo

What type of treatment(s) :

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

Benzoyl Peroxide (BPO) YesNo

Glycolic Acid (AHA) YesNo

Lactic Acid (AHA) YesNo

Resorcinol YesNo

Salicylic Acid (BHA) YesNo

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

Facial Cosmetic Surgery YesNo

Botox Injections YesNo

Collagen Injections YesNo

Fillers YesNo

Light Treatments YesNo

Laser Resurfacing YesNo

Microdermabrasion YesNo

Other YesNo

HOMECARE:

What Skincare products are you currently using at home?

Cleanser:

Vitamin C:

Toner:

Exfoliants/Scrubs:

Moisturizer:

Specialty Products:

SPF:

Mask:

PRESCRIPTION PRODUCTS:

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

Adepalene (Differin®) YesNo

Azelaic Acid (Azelex®, Finacea™) YesNo

Tazarotene (Tazorac®) YesNo

Isotretinoin (Accutane) YesNo

Triluma™ YesNo

Metrogel YesNo

Other YesNo

Any other topical antibiotics:

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

Skin Cancer YesNo

Dermatitis YesNo

Keloid Scarring YesNo

Acne YesNo

Rosacea YesNo

Broken Capillaries YesNo

Treatment Reactions YesNo

Hypopigmentation YesNo

Hyperpigmentation YesNo

SUN PROTECTION:

Do you use a sunscreen? YesNo

What level of protection?

Do you sunbathe or participate in outdoor activities? YesNo

Do you tan in a tanning booth? YesNo

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

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

WHEN EXPOSED TO THE SUN DO YOU: Always burn, never tanAlways burn, sometimes tanSometimes burn, sometimes tanAlways tan

Do you feel your skin is sensitive? YesNo

WHAT SKIN CONDITIONS DO YOU WANT TO IMPROVE?

Acne and/or breakouts YesNo

Facial Scarring YesNo

Hyperpigmentation (freckles, age spots) YesNo

Hypopigmentation YesNo

Enlarged Pores YesNo

Fine Lines and Wrinkles YesNo

Other YesNo

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

explain please:

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.