Aesthetic Consultation Questionnaire Name* First Last Date* MM slash DD slash YYYY Your HealthWithin the last year, have you been under a dermatologist’s or other physician’s care?* Yes No Please specify.*Have you had any health problems in the past or present?* Yes No Please specify.*List any medications, supplements, vitamins, diuretics, slimming pills, Isotretinoin, etc. that you take regularly. Do you smoke? * Yes No Do you exercise regularly?* Yes No Do you follow a restricted diet?* Yes No Do you wear contacts?* Yes No Do you have metal implants, a pacemaker or body piercings?* Yes No Rate your level of stress on a scale of 1 to 512345Do you have any allergies? Latex, nickel etc.* Yes No Please list your allergies.* Have you ever had an allergic reaction to Aspirin?* Yes No Do you sunbathe or use tanning beds?* Yes No Do you drink more than 4 caffeinated beverages daily (coffee, tea soft drinks?)* Yes No Have you ever experienced claustrophobia?* Yes No Your SkinWhat are your specific concerns or challenges with your skin?*What skin care products are you currently using for your face?* Soap Cleanser Toner Moisturizer Masque Exfoliator Eye products Serums What skin care products are you currently using for your body?* Soap Shower gel Scrubs Oil Body Moisturizer Depilatory products Self tanners Have you had a chemical peel, microdermabrasion, laser or light therapy, an injectable, or other cosmetic procedures in the last month?* Yes No Have you waxed with the last 72 hours?* Yes No Do you use Retin-A, Renoova, Adapalene, or any other prescription skin products?* Yes No Was this in the last 3 months?* Yes No Have you taken isotretinoin (Accutane) within the last 6 - 12 months?* Yes No Are you currently using any products that contain the following ingredients?* Glycolic Acid Lactic Acid Any exfoliating scrubs Any hydroxy acid products Vitamin A derivative (i.e, Retinol) Do you ever experience these conditions on your skin?* Flakiness Tightness Obvious dryness What SPF sunscreen do you use on your face?* What SPF sunscreen do you use on your body?* Do you burn easily in moderate sunlight? * Yes No Have you had any direct sun exposure within the last 48 hours?* Yes No Do you have a tendency to redness?* Yes No Do you suffer from sinus problems?* Yes No Are you prone to cold sores or fever blisters?* Yes No Are you currently experiencing a breakout?* Yes No Do you ever experience burning, itching or stinging sensations on your skin?* Yes No Sex* Male Female Female Clients Are you taking oral contraceptives?* Yes No Are you pregnant or trying to become pregnant?* Yes No Are you lactating?* Yes No Are you currently having or due for your menstrual period?* Yes No Male Clients Do you have any shaving challenges? * Yes No Please specify.** 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* MM slash DD slash YYYY
