Microsoft word - skin care history.docx

Skin Care History
Please answer the following questions so that I may have a better understanding of your general health
and can appropriately address your skin care needs. Please Print.

Client name: __________________________________________________________
Address: _____________________________________________________________
Email Address: ________________________________________________________
Telephone #: (home) ______________________(work) ________________________
Age: _______under 21 ____21-30 ____31-40 ____41-50 ____51-60 ____60+
How did you hear about us? Please list: _____________________________________

Your Health
1. Within the last year, have you been under a plastic surgeon, dermatologist or other physician’s care?
2. Within the last nine months, have you undergone any surgery? ____ yes ____no
3. Have you had any health problems in the past or present? ____ yes ____no
If yes, please specify___________________________________________
4. List any medications, supplements, vitamins, diuretics, slimming tablets etc. that you
take regularly________________________________________________________
5. Do you smoke? ____ yes ____no
6. Do you exercise regularly? ____ yes ____no
7. Do you follow a restricted diet? ____yes ____no
8. Do you have metal implants, a pacemaker or body piercing? ____yes ____no
9. Do you wear contact lenses? ____yes ____no
10. Rate your level of stress on a scale of 1 to 4 (1=low stress, 4=high stress) _______
11. Are you allergic to aspirin? ____yes ____no Do you have any other allergies?
(including food and latex)?____________________________________________
Your Skin
12. Do you have any skin problems pertaining to your face or body? ____yes ____no
If yes, please specify_______________________________________________
13. What skincare products are you currently using?
Face: ___soap ____cleanser ____toner ____moisturizer ____exfoliator
___eye product
Body: ___soap ____cleanser ____toner ____moisturizer ____exfoliator
___eye product
Exfoliation History
14. Have you ever had chemical peels, microdermabrasion, or any other resurfacing treatments? ____yes
15. Do you use Accutane, Retin A, Renova, Adapalene or any other prescription skin care products? ____yes ____no in the last three months ____yes ____no 16. Are you currently using any products that contain the following ingredients? ____glycolic acid ____lactic acid ____any exfoliating scrubs ____any hydroxyl acid products ____vitamin A derivatives (i.e. retinol) page two

Moisture Hydration
17. How much plain water do you consume daily? __________________
18. How many alcoholic beverages do you consume weekly? _________
19. Do you ever experience these conditions on your skin? ____ flakiness
____tightness ____ obvious dryness
20. What SPF sunscreen do you use on your face? ____ body? ____
21. Do you sunbathe or use tanning beds? ____yes ____no

Capillary Activity
22. Do you burn easily in moderate sunlight? ____yes ____no
23. Do you blush easily when nervous? ____yes ____no
24. Do you have a tendency to redness? ____yes ____no
25. Do you suffer from sinus problems? ____yes ____no
Oil Secretion
26. Do you ever experience oily shine during the day? ____yes ____no
27. Do you ever experience skin breakouts? ____yes ____no
Nerve Activity
28. Do you drink more than 4 caffeinated beverages daily? (coffee,tea,soft drinks)
____yes ____no
29. Do you ever experience a burning,itching sensation on your skin? ____yes ____no
30. What is your pain threshold? ____low ____medium ____high
31. Have you ever experienced claustrophobia? ____yes ____no
32. What type of massage pressure do you prefer? ____light ____medium ____firm
33. Have you ever had a reaction to the following? ____cosmetics ____iodine ____pollen
____ food ____hydroxyl acids ____animals ____fragrance ____sunscreen ____other

Female Clients Only
34. Are you taking oral contraception? ____yes ____no
35. Are you pregnant or trying to become pregnant? ____yes ____no
36. Are you lactating? ____yes ____no
Male Clients Only
37. What is your current shaving system? ____ electric ____wet shave
38. Do you experience irritation from shaving? ____yes ____no
Questions to Discuss Every Visit
39. Are you currently having or due for your menstrual period? ____yes ____no
40. Have you started any new medication since your last visit? ____yes ____no
41. Have you had any recent dental x-rays? ____yes ____no
42. What are your skin care goals? __________________________________________
Signature: _________________________________________Date:_________________
Please Print Name_________________________________________________________
Acqua Blu Medical Spa & Plastic Surgery Center 04/09


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PHYSICAL EXAM FORM CAMPER INFORMATION Camper’s Name__________________________________________Date of Birth: ______________________ Parent/Legal Guardian: Please complete the Camper Information section above and provide this form and a copy of the camper’s completed Health History Form to your child’s physician. Physician: Please review the camper’s Health History Form and

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