Skin Care History Questionnaire 

Name *
Name
Phone Number *
Phone Number
Address
Address
Date of birth
Date of birth
Do you have Epilepsy or Diabetes *
If yes, you will only be treated with a doctors release!
Do you use Biore or snore strips?
Have you had any of the following?
Are you allergic to aspirin?
Are you allergic to Seaweed or Iodine?
Do you smoke?
Do you take nutritional supplements?
Are you on a diet?
Do you exercise?
Do you wear contacts?
Have you had facials before?
Are you currently having facials?
Have you had electrolysis or waxing in the past week?
Do you ever have those services done?
Have you have permanent makeup?
How is your general health?
Please check what (if any) products you are using currently
Please check all the conditions that you would like to improve
Have you ever had an allergic reaction to a product or cosmetic?
Do you use sunscreen / sunblock?
Do you sunbathe or do outdoor activities?
Have you ever had acne?
If yes, are you using any medication for acne?
Have you seen a dermatologist in the past year?
Are you presently under a doctors care?
Have you had cold sores?
Female Clients
Are you on hormone replacement therapy?
Are you taking birth control?
Are you pregnant or planning to be?
By typing my name below I agree that I have filled out this form to the best of my ability.