#103 - 565 17th Street · West Vancouver BC · V7V 3S9 Phone 604 - 925 – 2560 · Website www.westvanwellness.com Skin Care History Questionnaire Please help us provide you with a complete evaluation by carefully filling out this questionnaire. All of your answers will be held absolutely confidential. If you have questions, please ask. Thank you. Name_____________________________________________________________ Age________ M F Today's Date (Mo/Day/Year)____________________ Birth Date (Mo/Day/Year)__________________ E-Mail Address ________________________________________________________________________ Home Address________________________________ City______________ Postal Code__________ Occupation____________________ Home Phone__________________ Cell Phone_______________ Preferred method of communication: Home Phone Cell Phone Email Spouse’s Name ________________________________________________________________________ Children (Name/Age) ___________________________________________________________________ If the above is a child: Father's Name______________________________________________________
Mother's Name_____________________________________________________ How did you find out about our clinic? ____________________________________________________ If you are female, are you or is there any possibility that you might be pregnant? _________________ Do you have a history of epilepsy or do you have a pacemaker? ________________________________ Current Skin Concern(s) ______________________________________________________________________________________
______________________________________________________________________________________ What is your skin care goal? _____________________________________________________________
______________________________________________________________________________________ When did your problems begin? __________________________________________________________ Have you been given a medical diagnosis, if so what? _________________________________________ What have you tried to improve your skin concerns? Did you notice any improvement?
Have you ever had any kind of professional skin care treatment; such as laser therapy, microdermabrasion, chemical peels, glycolic or retinol treatments etc? If so when was your last treatment? ______________________________________________________________________________________ ______________________________________________________________________________________
Do you have any allergies or skin product sensitivities? Please list all and describe your reaction(s): ______________________________________________________________________________________
______________________________________________________________________________________ Does your skin tend to be sensitive? What has triggered sensitivity and reactions in the past? ______________________________________________________________________________________ Have you ever used or are you presently using any of the following; Retin-A (tretinoin), Accutane (isotretinoin), Tazorac (tazarotene), topical retinol (Vitamin A) or Vitamin C, glycolic acid, alpha hydroxy acids, beta hydroxy acids or any other exfoliating treatment? If so, which products, strength and dosage? ______________________________________________________________________________________ ______________________________________________________________________________________ Do you tan regularly or use tanning beds? How does your skin react to the sun? ______________________________________________________________________________________ Do you regularly wear sunscreen? If so, what level of SPF? ___________________________________ Present Skin Care Routine Please list which products you are presently using on your skin and how often you use them. Cleanser______________________________________________________________________________ Toner_________________________________________________________________________________ Day cream_____________________________________________________________________________ Night cream___________________________________________________________________________ Suncreen______________________________________________________________________________ Eye Cream____________________________________________________________________________ Lip Treatment_________________________________________________________________________
Specialty Creams and/or serums __________________________________________________________ Masks________________________________________________________________________________ Exfoliation Treatment___________________________________________________________________ Are you happy with your current skin routine? If not, what would you like to change? What isn’t working for you? ______________________________________________________________________________________ ______________________________________________________________________________________
El reconocimiento a numerosas iniciativas por el medio ambiente marca la celebración del décimo aniversario de SIGRE El reconocimiento a numerosas iniciativas por el medio ambiente marca la celebración del décimo aniversario de SIGRE • Mejor• Humberto Arnés• Teresa Ribera• Consejo Administración El acto de celebración del décimo aniversario de SIGRE Medicamento y Medio Ambie
Protokoll Sitzung des Forums der Vielfalt in Elmshorn mit Wahl des Vorstandes am 6. August 2013, 18:00 Uhr im Kollegiumssaal/Rathaus (Dieses Protokoll ist zu finden unter www.elmshorn.de / Freizeit & Soziales / Migration & Integration / Forum für Vielfalt / Aktuelles) Vorsitz: Maximino Canete Afonso (Vorsitzender) Stellvertreterin: Gülderen Soylu Beisitzerin: L
#103 - 565 17th Street · West Vancouver BC · V7V 3S9