A vital online healthcare waiver app for both business owners and customers.

CONFIDENTIAL SKIN HEALTH QUESTIONNAIRE

It's our goal to provide you with the best experience possible.

To help us get to know your skin better, and to ensure your safety and satisfaction with your service today, please complete the following questionnaire. Please answer all questions to the best of your ability.

Today's date: *

Please enter valid date.

First and Last Name: * Please enter your name.

Date of Birth: *

Please enter valid date.

Please fill in Address: *

Please enter address.

Phone number: * Please enter your phone number.

Dermatologist/Physician: * Please enter your answer here.

Dermatologist/Physician Phone: * Please enter your phone number.

Emergency Contact: * Please enter your answer here.

Emergency Contact Phone: * Please enter your phone number.

Your occupation: * Please enter your answer here.

Email: * Please enter your email.

Referred by: *

Friend

Drive-by

Youphoria Team Member

Gift Certificate

Other

Please select at least one choice above.

If it was a friend or Youphoria team member who referred you, please list his/her name: Please enter your answer here.

Service Provider Name: * Please enter your name.

What is the reason for your visit today? * Please enter your answer here.

What special areas of concern do you have? * Please enter your answer here.

EXPECTATIONS & HISTORY

If you selected other, please describe: Please enter your answer here.

Have you ever had a facial treatment in the past? *

Yes

No

Please select at least one choice above.

How was your experience? * Please enter your answer here.

How would you describe your skin? *

Normal

Dry

Oily

Combination

Sensitive

Sun Damaged

Please select at least one choice above.

How would you rate your skin? *

I: Always burns, never tans

II: Always burns easily, tans slightly

III: Burns moderately- tans gradually

IV: Seldom burns- always tans well

V: Rarely burns- deep tan

VI: Never burns- deeply pigmented

Please select at least one choice above.

Do you ever experience *

Flakiness?

Redness?

Tightness?

Excessive oily shine during day?

Please select at least one choice above.

What is your present skin regimen? *

Soap & water only

Moisturizer

Cleanser

Exfoliation

Toner

Sun block every day

Masque

Other

Please select at least one choice above.

If you selected other, please describe: Please enter your answer here.

Are you ever exposed to chemicals, oils, or other caustic substances that may aggravate your skin? *

Yes

No

Please select at least one choice above.

If yes, what are they? Please enter your answer here.

Do you blush easily? *

Yes

No

Please select at least one choice above.

If yes, what are the contributing factors?

Emotions

Foods

Temperature changes

Other

Please select at least one choice above.

If you selected other, please describe: Please enter your answer here.

Do you: *

Sun bathe?

Use a tanning bed?

None of the above.

Please select at least one choice above.

If so, how often? Please enter your answer here.

Have you ever had: *

Peels?

Microdermabrasion?

Facial surgery?

Cosmetic surgery?

Botox?

Collagen injections?

Laser resurfacing?

Microblading or facial tattooing?

None of the above.

Please select at least one choice above.

How recently? Please enter your answer here.

Are you under treatment for any current skin condition? *

Yes

No

Please select at least one choice above.

If yes, what? Please enter your answer here.

How does your skin heal? *

Quickly

With scarring

With pigmentation

Please select at least one choice above.

Do you bruise easily? *

Yes

No

Please select at least one choice above.

Do you get sores/blisters (Herpes Zoster/Shingles)? *

Yes

No

Please select at least one choice above.

What medications/hormone replacement/vitamins are you presently taking? * Please enter your answer here.

Have you ever used: *

Accutane?

Retin-A?

Renova?

Topical Antibiotics?

Differin?

Tazarac?

Hydroquinone?

Alpha Hydroxy Acids?

None of the above

Please select at least one choice above.

If so, when and for how long? Please enter your answer here.

Any personal or family history of skin cancer? *

Yes

No

Please select at least one choice above.

If so, please provide details: Please enter your answer here.

How would you describe your overall health? *

Excellent

Good

Fair

Poor

Please select at least one choice above.

Have you ever had a reaction to: *

Cosmetics?

Metals?

Medication?

Food?

Fragrance?

Airborne particles?

Other

None of the above

Please select at least one choice above.

If you selected other, please explain: Please enter your answer here.

FOR WOMEN

Oral contraceptives? *

Yes

No

Male- N/A

Please select at least one choice above.

Are you pregnant or trying to get pregnant? *

Yes

No

Male- N/A

Please select at least one choice above.

Are you taking hormone replacement? *

Yes

No

Male- N/A

Please select at least one choice above.

Do you experience hormone imbalances? *

Yes

No

Male- N/A

Please select at least one choice above.

FOR MEN

Do you shave with: *

Electric shaver?

Razor?

Female- N/A

Please select at least one choice above.

Do you experience skin breakouts? *

Yes

No

Female- N/A

Please select at least one choice above.

Do you have ingrown hair? *

Yes

No

Female- N/A

Please select at least one choice above.

LIFESTYLE & DIET

Is your stress level: *

High

Medium

Low

Please select at least one choice above.

Do you normally sleep well? *

Yes

No

Please select at least one choice above.

Do you regularly exercise? *

Yes

No

Please select at least one choice above.

Do you have food intolerances? *

Yes

No

Please select at least one choice above.

If so, please describe: Please enter your answer here.

Do you follow any special diet? *

Yes

No

Please select at least one choice above.

How many glasses of water do you consume daily? * Please enter your answer here.

How many cups of caffeine-type beverages (coffee, tea, soft drinks) do you consume daily? *

1-3 cups

4 or more

I don't consume caffeinated beverages

Please select at least one choice above.

In our treatment program, it may be necessary to recommend alterations to or additions in your home care regimen; would that be OK with you? *

Yes

No

Please select at least one choice above.

Your practitioner will recommend the appropriate schedule for future facial treatments or physician referral in order to achieve your skin improvement goals.

INFORMED CONSENT RELEASE

I fully understand all the questions above and have answered them all correctly and honestly. I understand that the services offered are not a substitute for medical care. I understand that the skin care professional will completely inform me of what to expect in the course of treatment and will recommend adjustments to my regimen if deemed necessary. I also am aware that individual results are dependent upon my age, skin condition, and lifestyle. I agree to actively participate in following appointment schedules and home care procedures to the best of my ability, so that I may obtain maximum effectiveness. In the event that I may have additional questions or concerns regarding my treatment or suggest home product routine, I will inform my skin care professional immediately.

I release and hold harmless the skin care professional, Youphoria LLC, and the staff harmless from any liability for adverse reactions that may result from this treatment.

POLICIES

We require 24-hours notice for cancellations. Cancellations for Monday must be made prior to 2:00pm on the Saturday before.
If you are not satisfied with your service or products, please contact your skin care professional within 24-hours after your appointment so that the situation may be corrected. It is our policy to provide you with the best professional service and products customized for your skin condition.
I have reviewed and fully understand Youphoria LLC's late cancellation and no-show policies, which are available for review at http://www.youphoriasalon.com/etiquette.

I have read and understood all of the foregoing information.

Your Signature *

Click to sign

Please sign here.

Please Enter Date *

Please enter valid date.