To schedule your appointment, please complete the skin health questionnaire below. CONFIDENTIAL SKIN HEALTH QUESTIONNAIRE Name * First Name Last Name Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Your Occupation Dermatologist/Physician Please include contact info Emergency Contact * First Name Last Name Phone * (###) ### #### Referred by: Friend E-mail Instagram/Facebook Walk-by Gift Certificate Website Other EXPECTATIONS and HISTORY 1. What is the reason for your visit today? * 2. What special areas of concern do you have? 3. Which conditions would you like to improve? * Acne scarring Hyperpigmentation Acne Broken capillaries Age & Sun spots Skin Tags Enlarged Pores Fine lines & wrinkles Rosacea Other 4. Have you ever had facial treatment in the past? * Yes No 5. What was your experience? 6. How would you describe your skin? * Normal Dry Oily Combination Sensitive/ Rosacea Sun Damaged Acne Acne-Prone 7. How would you rate your skin? * Always burn, never tan Always burns easily - Tans slightly Burns moderately – Tans gradually Seldom burn – Always tans well Rarely burns – Deep tan Never burns – Deeply pigmented 8. Do you ever experience any of the following? Flakiness Tightness Redness Excessive oily shine during day 9. What is your present skin regimen? * Select all that apply. Soap & Water only Cleanser Toner Masque Moisturizer Exfoliation Sun Block every day Serums Other 10. Are you ever exposed to chemicals, oils, or other caustic substances that may aggravate your skin? Yes No If yes, what are they? 11. Do you blush easily? Yes No If yes, what are the contributing factors? Emotions Foods Temperature Changes Work Related Stress Other 12. Do you: Sun bathe? Use a tanning bed? If so, how often? 13. Have you ever had any of the following? Chemical Peels Microdermabrasion Facial surgery Cosmetic Surgery Botox Collagen Injections Laser Resurfacing How recently? 14. Are you under treatment for any current skin condition? Yes No If yes, what? 15. Does your skin heal: Fast Scars Pigments 16. Do you bruise easily? Yes No 17. Do you get sores/blisters (Herpes Zoster/Shingles)? Yes No 18. What medications/hormone replacement/vitamins do you presently take? * 19. Have you ever used any of the following? Accutane® Retin-A® Tretinoin (Vitamin A) Topical Antibiotics Benzoyl Peroxide Topical Retinoid Hydroquinone Alpha Hydroxy Acids Beta Hydroxy Acids None of the Above If yes, when and for how long? 20. Any personal or family history of skin cancer? * Yes No Please provide detail 21. How would you describe your overall health? * Excellent Good Fair Poor 22. Have you had any of the following, past or present? * Acne Allergies Arthritis or Bursitis High Blood Pressure Low Blood Pressure Breast Implant(s) Cancer Cataracts Low Cholesterol High Cholesterol Claustrophobic Diabetes Diarrhea/constipation Eczema Epilepsy Hay Fever Headaches Heart Disease/Conditions Hepatitis HIV/AIDS Infections Lupus Menopause Metal Implants Pace Maker Phlebitis Serious Injury Sleep problems Thyroid Issues Varicose Veins Smoker Wear contact lenses 23. Have you ever had a reaction to: * Fragrance Airborne particles Cosmetics Metals Medication Food Skincare Products Other Please provide specifics FOR WOMEN Oral contraceptives? Yes No Are you pregnant or trying to get pregnant? Yes No Are you taking hormone replacement? Yes No Do you experience hormone imbalances? Yes No FOR MEN What do you shave with? Electric Shaver Razor Both Do you experience skin breakouts? Yes No Do you have ingrown hair? Yes No LIFESTYLE & DIET Is your stress level: High Medium Low Do you normally sleep well? Yes No Do you regularly exercise? Yes No Do you have food intolerances? Yes No If yes, please list: Do you follow any special diet? Yes No How many glasses of water do you consume daily? How many cups of caffeine-type beverage (coffee, tea, soft drinks) do you consume daily? 1-3 cups 4 or more In our treatment program, it may be necessary to recommend alterations to or additions in your home care regimen; would that be OK with you? Yes No Thank you for your submission! We will contact you to schedule your appointment. Booking Requirements: All clients must make an initial $25 deposit via Venmo @christinebach or Zelle @7143175885 to secure their appointment.
