Referred? Yes No
 By Whom?

Name:

Birthdate:

Address:

City:

State:

Zip Code:

E-Mail:

Cell Phone:

Are you pregnant? No Yes

Is this your first facial treatment? No Yes

Reason for your vist:

What are the specific areas of concerns?


Are you under a physician's care for a skin condition? No Yes

Are you on birth control pills currently? if yes please list.


Are you on a hormone replacement? If yes please list.


Do you wear contact lenses? No Yes

Do you experience stress often? No Yes

Have you been diagnosed with skin cancer? No Yes

Are you using: acutane, azelex, differin renova, retin-a, tazarac, glycolic or alpha hydroxy acids? How long have you been using each of the them?


Do you have acne? If yes for how long?

Do you experience frequent blemishes? If yes for how long

Do you have allergies? Please list


Are you taking any other medications? Please list.


Are you using any of the following products (please list): soap, cleansing milk, toner, scrub, mask, cream, sunscreen, other:


What is your daily water consumption?

Do you experience any of the following (please list): Flakiness, tightness, obvious dryness?


Do you experience oily skin or shine during the day? No Yes

Is your menstrual period occurring now or soon? No Yes

Are you currently taking any new medications?


Do you suffer from any of the following (please list): asthma, cardiac problems, eczema, epilepsy, fever blisters, headaches, chronic, hepatitis, herpes, or high blood pressure?


Have you had (please list): a hysterectomy, immune disorder, lupus, metal bones, pins or plates, pacemaker, psychological problems, skin diseases?


Any other concerns not listed here that should be noted?