Skin Consultation Questionnaire

First Name

Last Name

Best Phone (preferably mobile)

Do you have any special skin problems or concerns pertaining to your face or body?

Yes

If yes, please specify any special skin problems or concerns pertaining to your face or body.

Have you ever had chemical peels, laser, or microdermabrasion?

Yes

Yes, in the last month

Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, or Retinol/vitamin A derivative products?

Yes

Have you used any of the (above) products in the last 3 months?

Yes

Have you used an acne medication?

Yes

If yes, which medication/drug?

Products/Brands (where known)

Explanation about area(s) of concern.

Lips

Dehydrated

Cracked / Chapped

Other

Explanation regarding any allergic reaction checked above.

What SPF do you use on your face? How often/when?

Have you experienced Botox, Restylane or Collagen injections?

Yes

If yes, please specify.

FOR FEMALE CLIENTS: Any recent changes to, or from, your contraceptive treatment?

Yes

If yes, please specify what changes and when?

FOR FEMALE CLIENTS: Are you pregnant or trying to become pregnant?

Yes

FOR FEMALE CLIENTS: Are you lactating?

Yes

FOR FEMALE CLIENTS: Any menopause problems?

Yes

If yes, please specify.

FOR FEMALE CLIENTS: Are you undergoing any hormone replacement therapy?

Yes

If yes, please specify.

BY ADDING YOUR NAME AND TODAY'S DATE BELOW, YOU'RE CONFIRMING THE FOLLOWING: I understand and have completed this questionnaire thoughtfully. 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 at New Beginnings Day Spa are voluntary and I release this business and/or professional skincare professional from liability and assume full responsibility thereof.