CONFIDENTIAL SKIN HEALTH QUESTIONNAIRE

 
DATE:_________________

NAME:_____________________________________   DATE OF BIRTH:____________________ ___                                               

EMAIL ADDRESS:_____________________________                                                                       

MAILING ADDRESS:_________________________________________________________________

CITY/STATE/ZIP:____________________________________________________________________                                                                                                                                         
CELL:_______________________            ALT PHONE NUMBER: ______________________________       

 OCCUPATION:____________________________   REFERRED BY_____________________________

DO YOU SMOKE?__________      HOW OFTEN?__________       LIVING WITH A SMOKER?_________

HAVE YOU BEEN TREATED FOR: (PLEASE CIRCLE)

      ACNE              DEPRESSION            SKIN DISEASE              HIGH BLOOD PRESSURE

      COLD SORES                DIABETES CANCER

LIST ALL ALLERGIES:_________________________________________________________________                                                                                                                                
LIST ALL MEDICATIONS THAT YOU ARE CURRENTLY TAKING: ________________________________                                                        

ARE YOU PREGNANT?_________________              TRYING TO GET PREGNANT?_________________

ARE YOU PRONE TO COLD SORES:____________                       

CIRCLE YOUR CURRENT LEVEL OF STRESS:        1      2      3      4      5      6      7      8      9      10

HOW MUCH WATER DO YOU DRINK DAILY?_____ DO YOU TAKE SUPPLEMENTS/VITAMINS?_____

DO YOU EXERCISE?______ IF SO, HOW OFTEN:________

YOUR LAST SUNBURN?_________             DO YOU USE TANNING BEDS?__________

WHEN YOU GO OUT INTO THE SUN, DO YOU (CIRCLE ONE):

      ALWAYS BURN (I)           USUALLY BURN (II)        SOMETIMES BURN (III)           RARELY BURN (IV)

      VERY RARELY BURN (V)         NEVER BURN (VI)

HAVE YOU EVER BEEN UNDER THE TREATMENT PLAN OF A:

      DERMATOLOGIST        PLASTIC SURGEON         AESTHETICIAN

ARE YOU CONCERNED ABOUT SKIN CONDITIONS ON YOUR BODY? (CHECK ALL THAT APPLY)

      SUN SPOTS         SKIN LAXITY        DRY / ROUGH

WHAT SKIN LINE ARE YOU CURRENTLY USING?___________________________________________

DO YOU USE A DAILY ENVIRONMENTAL PROTECTION PRODUCT (SUNBLOCK)?___________ ______

IF NOT, WHY?__________________________

CIRCLE HOW YOU FEEL ABOUT THE OVERALL QUALITY OF YOUR SKIN:

      (BAD)    1     2     3     4     5     6     7     8     9     10 (FANTASTIC)

 YOUR SKIN TYPE IS? (PLEASE CHECK ONLY ONE):

      NORMAL          DRY/DEHYDRATED          OILY          ACNE/ACNE PRONE          ROSACEA

IN ORDER OF IMPORTANCE, PLEASE RANK 1 (MOST IMPORTANT) TO 5 (LEAST IMPORTANT)

____REDUCTION OF FINE LINES                                                ____ACNE SCARS

____REDUCTION OF BROWN SPOTS/SUN DAMAGE        ____REDUCTION OF REDNESS

____REDUCTION OF OIL/ACNE

 Signature:_______________________________________________    Date:____________________

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