Skinserenityspa.com

SKIN CARE TREATMENT CLIENT CONSULTATION FORM Name_________________________________________________ Date___________________________ Address_________________________________________City_________________St._________Zip_______ Home Phone _________________ Cell Phone __________________Email_____________________________ Date of Birth__________________ Emergency Contact____________________________________________ Occupation______________________________________________________________________________ Does your job require you to work outdoors for any period of time?_____ How long? __________________ How did you hear about us? ________________________________________________________________ What would you like to achieve from your treatment today? ______________________________________ What are your long term goals from your skin care therapy? _______________________________________ Please list any operations or serious illness in the past 5 (five) years:_____________________________________________________________________________________DO YOU SUFFER FROM ANY OF THE FOLLOWING ILLNESSES OR DISEASES? Please check mark Epilepsy_____ Cardiac Disease ______ Photo Sensitivity _____ Lupus ______ Cancer _____ Bleeding Disorders ____ Keloid Scaring _____ Clotting Disorders _____ Migraine _______ Cold Sores _______ Eczema _____Systemic Diseases _______ Diabetes______ Hormonal Imbalance ________ Psoriasis ______ Skin Disorders ________ Lumps/cysts ________ Have you ever had a skin care treatment/facial before? _______ When? __________ What? _______________ Have you ever had a body spa treatment before? ____________ When? __________ Massage _____ Salt Glow ______ Seaweed Wrap ______ Moor Mud _____ Body Scrub _____ Other _____ What is your ethnic background? ( Irish, Italian ETC.) _________________________________ Normal Oily Combination TZone Oily/Dry Freckled Sun Damaged Uneven/Blotchy Mature Wrinkled Saggy Firm Large Pores Small Pores Acne Milia Blackheads Occasional breakouts Rosacea Scarred Melasma Cystic Sallow Pigmented WHICH OF THE FOLLOWING BEST DESCRIBES YOUR SKIN TYPE ? (please circle one type number) I Creamy Complexion Always burns easily, never tans II Light Complexion Always burns, tans slightly III Light/Matte Complexion Burns moderately, tans gradually IV Matte Complexion Seldom burns, always tans well V Brown Complexion Rarely burns, deep tan VI Black Complexion Never burns, deeply pigmented Do you have any special concerns pertaining to your face or your body skin? ______ Specify__________________________________________________________________ Have you ever had chemical peels, laser resurfacing, or microdermabrasion?____________When?_______ Do you use Retin-A, Renova, Adapalene,Hydroxy Acid or Retinol vitamin A products?_______ Describe__________________________________________________________ Have you used any of these products in the last 3 months?________ Have you used Acne medication?______When?_______Which Drug?______________ Which skin care products are you currently using? Please list brand if known. Soap_________________________________ Shower Gel __________________________________________ Toner _______________________________ Body Lotions ________________________________________ Mask _______________________________ Sunscreen (what spf?) __________________________________ Eye Cream___________________________ Facial Cleanser _______________________________________ Night Cream _________________________ Day Moisturizer ______________________________________ Exfoliator ___________________________ Makeup _____________________________________________ Scrubs ______________________________ Lip Care _____________________________________________ Have you recently used self tanning products or treatments?________Specify__________________________ Have you used any of the following hair removal methods in the past 6 (six) weeks?______Circle all that apply. Shaving Waxing Electrolysis Plucking Stringing Depilatories Have you experienced BOTOX, RESTYLANE, COLLAGEN or other fillers or injectables?______When_____ PLEASE LIST ANY MEDICATION YOU ARE TAKING AT THIS TIME OR IN THE PAST 3 MONTHS _________________________________________________________________________________________ What SPF do you use on your face? ______ How often/when? _______________ What SPF do you use on your body? _____ How often/when? _______________________________________ What area of concern do you have regarding your: Breakouts/acne Blackheads/whiteheads Excessive oil/Shine Rosacea Broken capillaries Redness/rudiness Sun spot/liver spots/brown spots Uneven skin tone Wrinkles/fine lines Dehydrated Dull/dry skin Flaky skin Other EYES: Dehydrated Wrinkles Puffiness Dark circles LIPS: Dehydrated Wrinkles Chapped/cracked Have you ever had an allergic reaction to any of the following? Please circle all that apply. Cosmetics Medicine Food Animals Sunscreens Iodine Pollen AHAs Fragrance Shellfish Latex Drugs Other PLEASE explain____________________________________________________________________________ __________________________________________________________________________________________ Do you smoke? _____ How many per day? ___ Do you drink alcohol? ____ How many glasses per day? _____ How would you rate your diet/eating habits? POOR FAIR MODERATE EXCELLENT Do you eat fish regularly? _____ How much red meat do you eat? ________ Do you eat five (5) portions of fruit and vegetables daily? ________ How many dairy products do you consume in one week? _________ How would you rate your health at this moment? __________________________________________________ Do you take supplements? _______ Please list_________________________________________________ Please add any more information below if you feel we should know more about you, your lifestyle and your desired results from our treatments. __________________________________________________________ Are you taking oral contraceptives? ____ Specify _________________________________________________ Any recent changes to or from your contraceptive treatment? _____ Specify ____________________________ Are you pregnant or trying to become pregnant? ____________ Are you lactating? _______ Any Menopause problems? _____ Specify _______________________________ Are you undergoing hormone therapy replacement? _______ Specify __________________________________ What is your current shaving system? Please circle one. Dry shave Wet shave Electric shave Do you experience irritation from shaving? ______ In grown hairs? ______ May we call you at home or cell phone number to confirm future reservations? _______ May we contact you via email about future promotions and news? _____ I understand, have read and completed this questionnaire truthfully. I agree 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. The treatments I receive here are voluntary and I release this institution and /or skin care therapist from liability and assume full responsibility thereof. Parent/Guardian signature if under 18 years old______________________________________Date________ Client Signature____________________________________________________ Date__________________ Skin Care Therapist Signature________________________________________ Date __________________

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