Questionnaire

Save time during your skin care consultation and send your questionnaire beforehand!

We know your skin is precious to you! In order to ensure quality service and the proper skin care treatments, it is important that all the fields are answered accurately. Please note that some medications and skin care treatments within a certain period of time may affect whether a service can be rendered in accordance with medical and skin care standards. Some skin conditions may require more than one treatment and home care products to achieve the result desired. Results cannot be guaranteed due to individual skin type(s) and condition(s). You will be required to sign off on your understanding of this and the accuracy of your questionnaire at every skin care session as a waiver of liability.

Name
Address
City
State
ZIP
Home Phone
Alternate Phone
Date of Birth
Email Address
What type of work do you do?
Have you seen a Dermatologist in the past year?
If yes, please provide your Dermatologist's name, contact info and reason for visit	contact info and reason for visit'>
Are you presently under a Physician
If yes, please provide your Physician's name, contact info and reason for visit	contact info and reason for visit'>
Are you currently taking any medications?
If yes, please list
How is your general health?
Please rate your stress from 1-5 (5 being the highest)	1 2 3 4 5
Please select the following conditions you currently have or had experienced	anemia asthma cancer claustrophobia cold sores contact lenses diabetes eating disorder epilepsy fainting headaches heart attack hepatitis hernia high blood pressure high cholesterol hypertension irregular pulse low blood pressure lupus metal plate seizures stroke thyroid disorders tooth fillings varicose veins
Do you take nutritional supplements?
Do you exercise?
Do you have a tendency to scar?
Have you ever had an allergic reaction to any of the following	aspirin or salicylates milk apples citrus grapes ingredients in skincare products fish/marine or iodine latex
If you selected any of the allergies above, please explain
Please list any other known allergies
Have you ever had Herpes Simplex?
If yes, have you ever been treated with Denavir (Penciclovir), Zovirax (Acyclivor) or Abreva?
Are you being treated for Hepatitis?
Are you on hormone replacement therapy?
Are you presently taking birth control pills?
Are you currently having skin treatments?
If yes, what type of treatment(s)
Please select if you are presently using or have used in the past any of the following	Benzoyl Peroxide (BP) Glycolic Acid (AHA) Lactic Acid (AHA) Resorcinol Salicylic Acid (BHA) Sulfur Vitamin A Vitamin C Hydrocortisone (HC) Hydroquinone (HQ)
Do you have or have you had any of the following in the past 14 days?	facial cosmetic surgery botox injections collagen injections fillers light treatments laser resurfacing microderm abrasion chemical exfoliation (peels) extractions permanent cosmetics waxing laser hair removal hair treatments (perm/color/etc.)
Other
What skincare products are you currently using at home?	Cleanser Toner Moisturizer SPF Vitamin C Exfoliants/Scrubs Specialty Products Mask
Please list the names of the corresponding products.
Please select if you are presently experiencing or have experienced any of the following (select all that apply using CTRL)	skin cancer dermatitis keloid scarring acne rosacea broken capillaries treatment reactions hypopigmentation hyperpigmentation
Please select all prescription products you are taking or have taken	Tretinoin (Retin A; Retin-A Micro; Renova; Avita) Adepalene (Differin) Azelaic Acid (Azelex; Finacea) Tazarotene (Tazorac) Isotretinoin (Accutane) Triluma Metrogel
Please list any other topical antibiotics
Do you use a sunscreen?
What level of protection?
Do you sunbathe or participate in outdoor activities?
Do you tan in a tanning booth?
Have you tanned in a tanning booth in the last 14 days?
Have you had any direct sun exposure in the last 10 days?
When exposed to the sun do you:	Always burn but never tan Always burn and sometimes tan Sometimes burn and sometimes tan Always tan
Do you feel your skin is sensitive?
What skin conditions do you want to improve? (select all that apply using CTRL)	acne and/or breakouts facial scarring hyperpigmentation (freckles/age spots) hypopigmentation enlarged pores fine lines and wrinkles rosacea uneven tone uneven texture dehydration oily sun damaged
Other
Is there any other necessary information your skincare specialist should know before beginning your treatment?