Contact Details
Name:*
Address:
Phone:*
Email:*
Age:
Your health
Within the last year, have you
Within the last year, have you
Within the last nine months,
Have you had any of these health
List medications, supplements, vitamins, diuretics, slimming tablets etc. that you take regularly:
Do you smoke?
Do you follow a restricted diet?
Do you have regular sleep patterns?
Do you wear contact lenses?
Do you have metal implants or a pacemaker?
Your skin
With what temperature of water do you cleanse?
Do you have any special skin
What skin care products are
Exfoliation History
Have you ever had chemical peels, laser, microdermabrasion or any resurfacing treatments?
In the last month?
Do you use Accutane, Retin A, Renova or Adapalene?
In the last 3 months?
Do you use an acne medication?
In the last 6 months?
Are you currently using any products
(i.e. retinol)
Moisture Hydration
How much plain water do you consume daily?
How many alcoholic beverages
Do you ever experience these
What spf sunscreen do you use on your face?
What spf sunscreen do you use on your body?
Do you sunbathe and/or use tanning beds?
Capillary Activity
Do you burn easily in moderate sunlight?
Do you blush easily when nervous?
Do you have a tendency to redness?
Do you suffer from sinus problems?
Oil Secretion
Do you ever experience oily shine during the day?
Do you ever experience skin breakouts?
Nerve Activity
Do you drink caffeinated beverages?
Do you ever experience a burning,
What is your pain threshold?
Have you ever had a reaction
Female Clients Only
Are you taking oral contraception?
Are you pregnant or trying to become pregnant?
Are you lactating?
Male Clients Only
What is your current shaving system?
Do you experience irritation from shaving?
Do you experience ingrown hairs?
Confirmation and signature
*
*
.jpg)
