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Anti-Aging Centers Skincare Consultation Card
NAME: ______________________________________ DATE OF BIRTH: _____/_____/_____
ANTI AGING CENTERS OF CONNECTICUT
ANTI-AGIN c
of Connecticut
YOUR HEALTH
1. Within the last year, have you been under a dermatologist’s or other physician’s care?
If yes, please specify: ______________________________________________________________________ 2. Have you had any health problems in the past or present?
If yes, please specify: ______________________________________________________________________ 3. List any medications, supplements, vitamins, diuretics, slimming pills, Isotretinoin, etc. that you take regularly:
__________________________________________________________________________________________________
4. Do you smoke?
5. Do you exercise regularly?
6. Do you follow a restricted diet?
7. Do you wear contact lenses?
8. Do you have metal implants, a pacemaker or body piercings?
9. Rate your level of stress on a scale of 1 to 5 (1 = low stress, 5 = high stress): ____________________________________
allergies?
If yes, please specify: ______________________________________________________________________ 11. Do you sunbathe or use tanning beds?
12. Do you drink more than four caffeinated beverages daily (coffee, tea, soft drinks)?
13. Have you ever experienced claustrophobia?
14. Have you had any laser/IPL/radio frequency treatments or injectables in the past month?
If yes, please specify: _____________________________________________________________________ YOUR SKIN
1. What are your specific concerns/challenges with your skin? _________________________________________________
2. What skincare products are you currently using?
FACE: [ ] soap [ ] cleanser [ ] toner [ ] moisturizer [ ] masque [ ] exfoliator [ ] eye products 3. Have you ever had chemical peels, microdermabrasion, or any resurfacing treatments?
In the last month?
4. Do you use Retin-A, Renova, Adapalene or any other prescription skin products?
In the last 3 months?
5. Are you currently using any products that contain the following ingredients?
[ ] glycolic acid [ ] lactic acid [ ] any exfoliating scrubs [ ] any hydroxy acid product [ ] Vitamin A derivatives (i.e. Retinol) 6. Do you ever experience these conditions on your skin? [ ] flakiness [ ] tightness [ ] obvious dryness
7. What SPF sunscreen do you use on your face? _________________ Body? _________________
8. Do you burn easily in moderate sunlight?
9. Do you have a tendency to redness?
10. Do you ever experience burning, itching or stinging sensations on your skin?
FEMALE CLIENTS ONLY
1. Are you taking oral contraception?
2. Are you pregnant or trying to become pregnant?
lactating?
4. Are you currently having or due for your menstrual period?
MALE CLIENTS ONLY
1. Do you have any shaving challenges?
If yes, please specify: ___________________________________________________________________ QUESTIONS TO DISCUSS EVERY VISIT
1. Have you started any new medication since your last visit?
I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be Client Signature: _________________________ Date: __________ Client Signature: _________________________ Date: __________ Client Signature: _________________________ Date: __________ Client Signature: _________________________ Date: __________ Client Signature: _________________________ Date: __________ Client Signature: _________________________ Date: __________ Client Signature: _________________________ Date: __________ Client Signature: _________________________ Date: __________

Source: http://anti-aging-centers.com/wp-content/uploads/2013/03/skincare-consultation-card-web.pdf