CONSULATION FORM

Please fill out the information below, print and bring with you on your next visit. Do not email as it contains your personal information.

Questions for Every Visit:
Any health problems since last visit?
Did you have any surgeries, dermatology or cosmetic treatments (laser,etc.)
since last visit? (if yes, what and when)
Any comments after last treatment?
Do you currently have a cold, flu, allergies, or sinuses?
Do you have any inflammation or boils on the face? Yes No
Do you use SPF (sunscreen) daily? How high? Yes No
Did you get any "Botox" done since last visit? (if yes- when?)
Did you get any "Fillers" done since last visit? (if yes- when?)
Do you use currently any Vitamin A treatments or other prescription products? Check all that apply:
Retinol Isotretinoin Accutane
Retin-A Differin Topical Steroids
Renova Adapalene Other:
Are you on any oral or topical Acne, Psoriasis or Eczema Treatments? (if yes- what?)
Have you started any new medication since your last visit? (if yes- what?)
When was your last peel (and what kind)?
Are you currently using any of the following products?
glycolic acid AHA/BHA Vitamin A
lactic acid any facial scrubs derivatives (eg: Retinol)
When did you have your last Microdermabrasion treatment?
Did you wax you face last 5 days? Yes No
Are you currently pregnant? Yes No
Have you had any recent X-rays (dental or any other)? Yes No
Are you currently having or due for menstrual period? Yes No
Are you currently taking blood thinners (Ibuprofen, Aspirin, Excedrin, etc)? Yes No
What are your skin concerns for today appointment?
My skin feels:
Dry & Dehydrated Sensitive & Irritated Oily & Congestive
What type of pressure do you prefer?
Light Medium Firm


Health:
Any health problems or concerns in a past or present?
List all the medication, supplements, vitamins, slimming pills or shakes,
diuretics, etc. that you take regularly:

Do you take cholesterol medications? Yes No
Do you drink alcohol? How often?
Do you have any metal implants, a pacemaker or body piercing? Yes No
Have you undergone any surgery within last year? (if yes- please specify)
Have you ever experienced heart problems, heart failure or had heart surgery? Yes No
Have you had or currently have any skin disorders or diseases? (if yes- please specify)
How many moles, sun spots, freckles, etc. do you have on your face and neck? 1-5 6-10 11-20 more than 20
Within last year, have you been under a dermatologist's or other physician's care? Yes No
Did you have any recent "cold sores"? (if yes- when?)
Have you ever had breakouts anywhere on your skin (other than lips) with blisters (herpes simplex)?
Please rate your immune defense system: 1-10 (low to highest)
How often do you get sick (cold, flu, etc.)
Do you exercise regularly? How often?
Please rate your stress level: 1-10 (low to highest)
Do you follow restricted diet? What kind?
What food do you avoid in your diet?
How much of the salt do you use daily? (pinch, teaspoon, etc.)
How much of the sugar do you use daily? (pinch, teaspoon, etc.)
Have you recently undergone a skin peel? When exactly?
What products do you use for skin care?
Have you ever had reaction to any of the following?
cosmetics animals salicylic acid
medication fragrance milk
pollen essential oils dust
seafood sunscreen yeast
iodine alpha-hydroxy acids wheat
food sugar  
List any allergies you have (drugs, makeup, skin or food allergies):
Whom should we call in case of an emergency?
Check any conditions below that you have or have you ever had:
Abnormal Heart Condition Claustrophobia Corneal Abrasions
Cold Sores Anxiety attacks Eye surgery or Injury
Herpes Simplex Fainting Spells/Dizziness Dry Eye
Circulatory Problems Heart Failure Blepharoplasty (eyelid surgery)
Shingles Pacemaker Visual Disturbances
Epilepsy Open Heart Surgery Do you wear contact lenses?
Ovarian Cyst Diabetes High or Low Blood Pressure
Hepatitis Prolonged Bleeding Hemophilia
Cataracts Glaucoma Cancer
Tumors/Growths/Cysts Chemotherapy/Radiation THYROID problems
Irregular menstrual cycles?
Do you use tobacco products?
Are you using any eye drops or other ocular medications?
Have you ever experienced hyper pigmentation from an injury?
Are you currently taking aspirin or ibuprofen?
When was your last eye exam?
Examining Physician:
 

Skin:
Did you ever have a facial before? If yes when the last?
Would you consider your skin VERY SENSITIVE?
Do you scar easily? Yes No
What is your ethnicity?
Have you ever scarred after facial wax, peel or extractions? Yes No
When you cut yourself, do you heal easily? Yes No
After breakouts, how long do your blemishes stay visible? Yes No
Have you experienced hyper pigmentation from an injury? Yes No
Do you bruise or bleed easily? Yes No
Please rate your pain tolerance: 1-10 (low to highest)
What skin care products do you currently use?
soap toner masque
scrubs self-tanners exfoliator
cleanser eye products sun screen
     

Oil Secretion & Moisture Hydration:
How often do you experience breakouts?
Do you ever experience oily shine during the day?   Yes   No
How much water do you drink a day?
How many caffeinated beverages do you drink daily? (Coffee, tea, soft drinks) None 1-2 3-4 5+  
How many alcohol beverages do you drink daily/weekly? None 1-2 3-4 5+  
Do you ever experience: flakiness tightness dryness  

Capillary activity:
Do you take hot showers/baths? Yes No
Any reaction after hot showers/baths? Yes No
Any strong reaction to the cold temperature? Yes No
Do you blush easily when nervous? Yes No
Do you have a tendency to redness? Yes No
Do you suffer from sinus problems Yes No
Do you burn easily outdoors? Yes No
Do you have broken capillaries on your face/neck/chest? Yes No
Do you experience burning/ itching sensation on your face? Yes No

Female client only:
Are you pregnant or trying to become pregnant? Yes No
Are you taking oral contraception? Yes No

Male client only:
Do you experience irritation from shaving? Yes No
Do you experience ingrown hair? Yes No
What cosmetics do you use for your shaving daily routine?

For Facial/Body Wax:
Have you had any adverse reactions to waxing in the past?
Have you experienced hyper pigmentation from an injury?
Are you currently taking blood thinners (Ibuprofen, Aspirin, Excedrin, etc)? Yes No
Do you use currently any Vitamin A treatments or other prescription products? Check all that apply:
Retinol Isotretinoin Accutane
Retin-A Differin Topical Steroids
Renova Adapalene Other:
Are you taking any Oral/ Topical Acne, Psoriasis or Eczema Treatments?

Image Upload Facial Photos
Attach Image Here
   

I understand that waxing can cause skin damage up to and including permanent scarring. The use of certain medications or treatments can increase this risk. I understand the risk and consent to hair waxing services being performed on me.

I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I understand the risks (allergies, wax burns, etc.) and consent to the facial treatment being performed on me.

  I Agree



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