Name __________________ address_________________________________________

Skin Care Profile

Name ___________________________ Address_______________________________________
City_____________________________ State ______ Zip _________ Date of Birth___________
Email:___________________________ Phone(Day)______________(Night)________________
Profession_____________________ How did you hear about us? _________________________
Your Health
1. Within the last year, have you been under a dermatologist or other physician’s care? 2. Within the last nine months, have you undergone any surgery? Yes/No If yes, please specify ___________________________ 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 wear contact lenses? Yes/No 9. Do you have metal implants, a pacemaker or body piercings? Yes/No 10. Rate your level of stress on a scale of 1 to 4 (1 = low stress, 4 = high stress): ___
Your Skin
11. Do you have any special skin problems pertaining to your face or body? If yes, please specify ___________________________ 12. What skin care products are you currently using? Face: _ Soap _ Cleanser _ Toner _ Moisturizer _ Masque _ Exfoliator _ Eye Products Body: _Soap _Shower gel _ Scrubs_ Oil _Body Moisturizer _ Depilatory Products _Self Tanners Exfoliation History
13. Have you ever had chemical peels, microdermabrasion, or any resurfacing treatments? 14. Do you use Accutane, Retin A, Renova, Adapalene or any other prescription skin products? Yes/No … in the last 3 months? Yes/No 15. 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) Moisture Hydration
16. How much plain water do you consume daily? ___ 17. How many alcoholic beverages do you consume weekly? ___ 18. Do you ever experience these conditions on your skin? 19. What SPF sunscreen do you use on your face? ___ Body? ___ 20. Do you sunbathe or use tanning beds? Yes/No/Occasionally
Capillary Activity
21. Do you burn easily in moderate sunlight? Yes/No/Occasionally 22. Do you blush easily when nervous? Yes/No/Occasionally 23. Do you have a tendency to redness? Yes/No/Occasionally 24. Do you suffer from sinus problems? Yes/No/Occasionally Oil Secretion
25. Do you ever experience oily shine during the day? Yes/No/Occasionally 26. If yes, what time of day are you noticing a shine on your face? _______________ 27. Do you ever have skin breakouts? Yes/No/Occasionally
Nerve Activity
28. Do you drink more than 4 caffeinated beverages daily? (coffee, tea, soft drinks) ___ 29. Do you ever experience a burning, itching sensation on your skin? Yes/No/Occasionally 30. What is your pain threshold? Low/Medium/High 31. Have you ever experienced Claustrophobia? Yes/No/Occasionally 32. What type of massage do you prefer? Light/Medium/Firm 33. Have you ever had a reaction to the following? _Cosmetics _Medicine _Iodine _Pollen _Food _ Hydroxy Acids _Animals _Fragrance _Sunscreens _Other (specify) ____________
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 37. Are you currently having or due for your menstrual period? Yes/No
Male Clients only
38. What is your current shaving system? Electric/Wet Shave 39. Do you ever experience irritation from shaving? Yes/No 40. Do you experience ingrown hairs? Yes/No
Questions to discuss every Visit
41. Have you started any new medication since your last visit? Yes/No If yes, please specify ___________________________ 42. Have you had any recent dental x-rays? Yes/No 43. What are your skin care goals? ______________________________________________ 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 relevant to my treatment. Signature ___________________________________________________ Date ____________

Source: http://www.bodyrest.com/assets/PDFs/BodyRestSkincareProfile.pdf