Fabulousskinseattle.com

Name: ______________________________________ Phone #:_____________________ Birthday: _______________Address:_____________________________________________________ Email:________________________________ Emergency Contact Name & Number: _________________________________________________________________How did you find us?________________________________________________________________________________(internet search, facebook, twitter, walking by, newspaper, friend. If by another client, please include his/her name.)Which of the following best describes your skin type? (Please circle one type number) Have you ever had chemical peels, laser or microdermabrasion & when?__________________________________________________________________________________________________Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/Vitamin A derivative products?__________________________________________________________________________________________________What skin care products are you currently using? What is your skin care routine? __________________________________________________________________________________________________Do you exfoliate your skin? If so how often? What product do you use? __________________________________________________________________________________________________What areas of concern do you have regarding your skin? (Circle any that apply) Eyes: Dehydrated Wrinkles Puffiness Dark Circles Other__________________________________Have you ever had an allergic reaction to any of the following? Cosmetics Other ___________________________________________________________________________________Do you use SPF on your face? Body? How often? What do you use?__________________________________________________________________________________________________Have you experienced Botox, Restylane or Collagen Injections? If so, please specify:__________________________________________________________________________________________________Have you been under the care of a physician, dermatologist or other medical professional within the past year? If so, please explain: ________________________________________________________________________________Any recent surgery, including plastic surgery? ____________________________________________________________Have you had any piercing, tattoos, or permanent cosmetics? ______________________________________________ Have you ever had any of these health conditions in the past or present? (Circle any that apply) Do you smoke? Y : NDo you follow a restricted diet? If so, please specify: ______________________________________________________Do you follow a regular exercise program? If so, please specify: ____________________________________________What is your stress level? High? Medium? Low?List any medications you take regularly: _________________________________________________________________List any over the counter medications (including vitamins, supplements, aspirin, etc) you take regularly:__________________________________________________________________________________________________Do you use Retin-A, Renova, Adapalene, Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid, or Retinol/Vitamin A derivative products? If so, please describe: ____________________________________________________________Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma? If so please describe: _________________________________________________________________List your daily consumption of: Water _______________ Caffeine ______________ Alcohol ______________Do you experience any problems sleeping? Y : N How many hours do you sleep each night? ________Do you wear contact lenses? Y : NHave you been exposed to the sun or used a tanning bed in the last 48 hrs? Y : NHow frequently are you exposed to the sun or use a tanning bed? ___________________________________________Do you have any metal implants or wear a pacemaker? Y : NHave you ever experienced claustrophobia? Y : NHave you ever had an adverse reaction after using any skin care product? (Please circle any that apply)Rash Irritation Peeling Sun Sensitivity Breakout If so, please explain: ________________________________________________________________________________ May I call you at home, work, or cell phone number to confirm future appointment? Y : N May I contact you via mail/email about future promotions and news? Y : N I understand, have read and completed this questionnaire truthfully. I agree that 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 professional from liability and assume full Client Signature: _________________________________________________ Date: ____________________

Source: http://www.fabulousskinseattle.com/NewClientForm.pdf