Minor First and Last Name: *
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Parent/guardian name: *
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Email: *
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Phone number: *
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Occupation: *
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Ethnicity/nationality: *
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How did you discover us? *
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Have you received a facial treatment before? If so, what have you received? *
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When was the last time you received a facial treatment? *
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What is your monthly budget for skin care treatments/products? *
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What concerns do you have with your skin? *
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Please list your current morning routine. *
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Please list your current night routine. *
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Do you lay out in the sun or use tanning booths? *
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Do you use sunscreen? When? What SPF rating? *
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Are you currently using Retin-A, Renova, Adaphalene, Retinol or any Vitamin A products? *
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If you're using a Vitamin A product, how long have you been using it and how frequently? *
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Do you pick at your skin? *
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Have you received any injections like Botox, Restylane, Juvederm etc. on the area that is being treated in the last two weeks? *
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Have you waxed, shaved or used any depilatory methods on the area that is being treated within the last 3 days? *
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How many cups of water do you drink daily? (1 cup = 8 ounces) *
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Do you drink coffee, tea or soda? How many cups per day? *
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How many alcoholic beverages do you consume weekly? *
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Do you follow a restricted diet? Explain: *
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Do you smoke tobacco or marijuana products? *
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Do you exercise? How often? *
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What is your normal stress level? *
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How many hours do you sleep each night? *
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Do you spend time outside? (Beach, gardening, exercise, walk dogs, etc.) *
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Please list any and ALL known allergies including foods & cosmetics: *
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Do you currently have or have experienced any of the following?
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Please list any other health conditions that might affect your treatment: *
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Are you currently taking any of the following medications?
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Please list any other medication that might affect your treatment: *
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Please list any over-the-counter medications you take regularly (including vitamins & supplements): *
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Do you currently have any injuries including cuts, bruises or broken bones that need to be avoided? Explain: *
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Are you currently on any type of birth control? (Pills, IUD, Shots etc.)
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If yes, what type of birth control are you using?
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List any recent changes to your birth control:
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Are you currently pre-menopausal or in menopause?
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Are you pregnant or trying to become pregnant?
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Are you currently breast feeding?
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I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. I will inform the esthetician of any changes to my medication or health. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.
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Parent/guardian signature: *
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