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| Within the last year, have you been under a dermatologist or other physician's care? |
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Yes No |
Within the last nine months, have you undergone surgery?
If yes, please specify:
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Yes No |
| Have you had any of these health problems in the past or present? |
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Yes No |
List medications, supplements, vitamins, diuretics, slimming tablets, etc... that you take regularly:
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Yes No |
| Do you exercise regularly? |
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Yes No |
| Do you follow a restricted diet? |
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Yes No |
| Do you wear contact lenses? |
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Yes No |
Your Skin... |
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Do you have any special skin problems pertaining to your face and body?
If yes, please specify:
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Yes No |
What skin care products are you currently using?
Face:
SoapCleanserTonerMoisturizerMasque
ExfoliatorEye Products
Body:
SoapShower GelScrubsOilBody Moisturizer
Depilatory ProductsSelf Tanners |
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Exfoliation History... |
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| Do you use Accutane, Retin A, Renova, Adapalene or any other presciption skin products? |
Yes No
In the last month?
Yes No |
Are you currently using any products that contain the following ingredients?
Glycolic Acid
Lactic Acid Any Exfoliating Scrubs
Any Hydroxy Acid Product
Vitamin A Derivatives (i.e. retinol) |
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Moisture Hydration... |
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| How much plain water do you consume daily? |
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| How many alcoholic beverages do you consume weekly? |
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| Do you ever experience these conditions on your skin? |
Flakiness
Tightness
Obvious Dryness |
| What SPF sunscreen do you use on your... |
Face:
Body:
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| Do you sunbathe or use tanning beds? |
Yes No |
Capillary Activity... |
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| Do you burn easily in moderate sunlight? |
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 |
Oil Secretion... |
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| Do you ever experience oily shine during the day? |
Yes No
Occassionaly |
| Do you ever experience skin breakouts? |
Yes No
Occassionaly |
Nerve Activity... |
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| Do you drink more than 4 caffeinated beverages daily? (coffee, tea, soft drinks) |
Yes No |
| Do you ever experience burning, itching sensation on your skin? |
Yes No |
Have you ever had a reaction to any of the following?
Cosmetics Medicine Iodine Pollen Food
Hydroxy Acids Animals Fragrance Sunscreens |
Other
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Questions To Discuss Every Visit... |
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What are your skin care goals?
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