Consultation Card Date* MM slash DD slash YYYY Name* First Last Date of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home Phone*Business PhoneCell PhoneEmail* Physician*Physician Phone*Emergency Contact*Emergency Contact Phone* Daily Basics What is your current skincare routine/regime?*I wash my face: 1x daily 2x daily more than 2x daily hardly ever What types of skincare are you currently using?* soap toner mask cleanser moisturizer scrub/peel other ExplainI use the following haircare products shampoo conditioner hairspray hair gel palm aide leave-in conditioner hair oils masks I shampoo and condition my hair how often?* daily more than once a day a few times per week once a week Your Health Have you been under the care of a physician, dermatologist or other medical professional within the past year?* Yes No ExplainAny recent surgery, including plastic surgery?* Yes No ExplainAny skin cancer?* Yes No ExplainHave you had any piercings, tattoos, or permanent cosmetics?* Yes No Where on your person?Have you had any of these health conditions in the past or present?(Please check all that apply and provide additional information in the space provided) Cancer Hormone imbalance Systemic disease High blood pressure Spinal injury Thyroid condition Hysterectomy Diabetes Heart problem Varicose veins Arthritis Asthma Eczema Epilepsy Seizure disorder Fever blister Headaches (chronic) Hepatitis Herpes Frequent cold sores Immune disorders HIV/AIDS Lupus Metal bone pins or plates Phlebitis, blood clots, poor circulation Blood clotting abnormalities Psychological treatment Insomnia Keloid scarring Skin disease/skin lesions Any active infection Has your physician discussed concerns about raising your body temperature?* Yes No ExplainDo you smoke?* Yes No Do you follow a restricted diet?* Yes No SpecifyDo you follow a regular exercise program?* Yes No What is your stress level?* High Medium Low List any prescription medications you take orally or apply topically, regularly List any over the counter medications (including vitamins, herbal 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?* Yes No Describe Have you used any of these products in the last 3 months?* Yes No Have you used an acne medication?* Yes No When?Which Drug?Do you form thick or raised scars from cuts or burns?* Yes No Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?* Yes No DescribeList your daily consumption of:Water*Caffeine*Alcohol*Do you experience any problems sleeping?* Yes No How many hours do you typically sleep each night?*Do you wear contact lenses?* Yes No Have you been exposed to the sun or used a tanning bed in the last 48 hours?* Yes No How frequently are you exposed to the sun or use a tanning bed?* Infrequently Frequently Regularly Do you have any metal implants or wear a pacemaker?* Yes No Have you ever experienced claustrophobia?* Yes No Do you suffer from sinus problems?* Yes No Have you ever had an adverse reaction after using any skin care product? Rash Irritation Peeling Sun Sensitivity Breakout Have you ever had an allergic reaction to any of the following? Cosmetics Medicine Food Animals Sunscreens Iodine Pollen AHAs Fragrance Shellfish Latex Drugs Other What was it?What happened?Gender* Female Male Are you taking oral contraceptives?* Yes No SpecifyAny recent changes to or from your contraceptive treatment?* Yes No What and when?Are you pregnant or trying to become pregnant?* Yes No Are you lactating?* Yes No Any menopause problems?* Yes No What and when?Please use this space to complete answers where space was insufficient. (Please include the question)ConsentI 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. I am aware that it is my responsibility to inform the esthetician/skin care therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof. I understand Δ
