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Your Details |
Client name: Last:
First:
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Client address:
apt/unit:
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City:
state: postcode:
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Telephone: Home:
Work:
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Email: |
Age Group:
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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?
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If yes, please specify: |
3. Have you had any health problems in the past or present?
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If yes, please specify: |
4. List any medications, supplements, vitamins, diuretics, slimming tablets etc. that you take regularly.
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If yes, please specify: |
5. Do you smoke?
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6. Do you exercise regularly?
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7. Do you follow a restricted diet?
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8. Rate your level of stress on a scale of 1 to 4 (1 = low stress, 4 = high stress) |
Your Skin |
9. Do you have any special skin problems pertaining to your face or body?
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10. What skin care products are you currently using?
face: soap cleanser toner moisturiser
masque
exfoliator eye products
body:
soap
shower gel
scrubs
oil
body moisturiser
depilatory products
self tanners |
Exfoliation History |
11. Have you ever had chemical peels, laser, microdermabrasion or any resurfacing treatments?
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in the last month? |
12. Do you use Accutane, Retin A, Renova, Adapalene or any other prescription skin products?
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in the last 3 months? |
13. 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 |
14. How much plain water do you consume daily? |
15. How many alcoholic beverages do you consume weekly?
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16. Do you ever experience these conditions on your skin? flakiness tightness obvious dryness |
17. What spf sunscreen do you use on your face?
body?
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18. Do you sunbathe or use tanning beds?
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Capillary Activity |
19. Do you burn easily in moderate sunlight?
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20. Do you blush easily when nervous?
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21. Do you have a tendency to redness?
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22. Do you suffer from sinus problems?
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Oil Secretion |
23. Do you ever experience oily shine during the day?
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24. Do you ever experience skin breakouts?
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Nerve Activity |
25. Do you drink more than 4 caffeinated beverages daily? (coffee, tea, soft drinks)
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26. Do you ever experience a burning, itching sensation on your skin?
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27. Have you ever had a reaction to any of the following?
cosmetics medicine iodine pollen food hydroxy acids
animals fragrance sunscreens other |
Female Clients Only |
28. Are you taking oral contraception?
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29. Are you pregnant and seeing changes in your skin?
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30. If yes, what changes are you experiencing?
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Male Clients Only |
31. What is your current shaving system?
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32. Do you experience irritation from shaving?
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33. Do you experience ingrown hairs?
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Your Goals |
34. What are your skin care goals?
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