Facial Form Facial Form Name* First Last Gender* Female Male Facial QuestionnaireWhen was your last Facial or Skin treatment?Neverless than 1 month ago1 - 3 months ago3 - 6 months ago6 - 12 months agomore than 12 months agoWhat's the purpose for your visit today?* To relax and be pampered Routine cleaning minimize wrinkles improve elasticity acne other skin concern Describe other skin concern*Do you work outdoors? Yes No Which of the following best describes you skin type?* I Creamy Complexion: Always burns easily, never tans II Light Complexion: Always burns, tans slightly III Light/Matte Complexion: Burns moderately, tans gradually IV Matte Complexion: Seldom burns, always tans well V Brown Complexion: Rarely burns, deep tan VI Black Complexion: Never burns, deeply pigmented Have you every had chemical peels, laser or microdermabrasion?* Yes No When did you have your last chemical peel, laser or microdermabrasion* within the last 30 days 1-3 months ago more than 3 months ago Do you use Retin-A, Renova, Adapalene, Hydroxyl Acid or Retinol/vitamin A derivative products?* Yes No Are you currently using any acne medication?* Yes No What acne medication did you use? (check all that apply)* Proactive Accutane other other acne medication*When did you last use any acne medication* within the last month 1-3 months ago more than 3 months ago What skin care products are you currently using? (check all that apply) soap shower gels toner body lotions mask sunscreen eye product cleanser night moisturizer/cream day moisturizer/cream exfoliator make-up products other What other skin care products do you use?*Have you recently used any self-tanning lotions, creams or treatments?* Yes No Have you used any of the following hair removal methods in the past six weeks? (check all that apply) Shaving Waxing Electrolysis Tweezing Threading Depilatories Skin Concern:What areas of concern do you have regarding your skin? (check all that apply) Breakouts/acne Blackheads/whiteheads Excessive oil/shine Rosacea / hypersensitive Broken capillaries Redness / ruddiness Sun spot / Live spot / Brown spot Uneven skin tone Sun damage Wrinkles / fine lines Dull / dry skin Flaky skin Dehydrated skin other What other skin concern do you have?*Eye Concerns:What areas of concern do you have regarding your eyes? (check all that apply) Dehydrated Wrinkles Puffiness Dark circles other What other eye concern do you have?*Lips:What areas of concern do you have regarding you lips? (check all that apply) Dehydrated Cracked/chapped lips other What other concern do you have for your lips?*Allergic Reactions:Have you ever had an allergic reaction to any of the following? (check all that apply) Cosmetics Medicine Food Animals Sunscreens Iodine Pollen AHAs Fragrance Shellfish Latex Drugs other Explain your other allergic reaction.*Sunscreen usage:What SPF do you use?* 30 or greater 20 - 30 10 - 20 less than 10 none How often do you re-apply sunscreen when in the sun? never every 3 - 4 hours every 1 or 2 hours Have you had any recent tanning bed or sun exposure that changed the color of your skin?* Yes No Injectables:Have you experienced Botox, Restylane or Collagen injections?* Yes No Female Guests Only:Are you taking oral contraceptives?* Yes No What oral contraceptives are you taking and when?Any recent changes to or from your contraceptive treatment?* Yes No What changes did you make to your contraceptive treatment and when was the change made?*Are you pregnant or trying to become pregnant?* Yes No Are you lactating?* Yes No Any menopause problems?* Yes No Describes the problems you're experiencing with menopause.*Are you undergoing any hormone replacement therapy?* Yes No Describe you hormone replacement therapy.* Male Guests Only:What is your current method for shaving?* Razor with shaving cream Electric Razor Do you experience any irritation from shaving?* Yes No Do you have any ingrown hairs?* Yes No Thank You! Please click the submit button below... Δ
