Esthetics Intake

Date of Birth (MM/DD/YYYY)

Gender

Occupation

Mobile Phone

Home Phone

Work Phone

Source of Referral

Country

Province / State

Postal / Zip Code

Emergency Contact

Emergency Phone

Relationship

Doctor's Name

Doctor's Phone

Doctor's Address

Oily Skin

Oily all over

Oily in t-zone

Dewy

Eczema or Rosacea (yes), location?

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How frequently are you experiencing this condition?

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How long have you been experiencing this condition?

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Visible Capillaries

Yes

If capillaries are showing is there also redness in the area?

Nose

Cheeks

Chin

Location of visible capillaries

Location of Redness

Nose

Cheeks

Chin

Uneven Skin Tone

Yes

What is the desired goal for your skin?

Keep skin healthy and balanced, preventative

Holistic skin correction

Wellness and maintaining a healthy lifestyle

Digestive issues

Assistance with health challenges

Please describe a brief history of your skin. Share any sensitivities/allergies (including seasonal).

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What is your current skin care routine? What products do you use?

Do you experience any sensations/symptoms when using any of your home care products? If yes, please specify?

What do you love about your skin?

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Do you have any concerns relating to your face or body? If so, please specify. When did they begin?

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Describe any factors which may be contributing to this onset.

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What makes it better? What makes it worse?

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Are you currently under the care of a dermatologist? If so, please specify.

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Do you currently use any topical medications? Which ones? How often?

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Please select all that apply?

Are you pregnant?

Trying to become pregnant?

Are you breastfeeding?

Have you recently had a change in birth control?

Other hormone-related experience?

Any hormonal therapy to the above?

None

Please list any areas where you have pain/discomfort (achy, throbbing, stabbing, numbness, tingling, etc).

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Please list any injuries and/or surgeries you have had and their respective dates.

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Please list any medical, vitamins, or supplements you are currently taking?

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How would you describe your digestion/gut health?

I feel good/balanced

I feel imbalanced

This has been an issue in the past

Currently working with someone to address it

Other

Do you follow a special diet? If so, please specify.

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How much water do you drink per day?

1-3 glasses (8 oz)

4-5 glasses

6-9 glasses

10+ glasses

Do you eat salads? If so, how often?

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Do you eat smoothies? If so, do you add ice?

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Do you juice? How often?

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Do you drink protein shakes or eat protein bars? If so, are they protein or vegan based?

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Do you eat fresh fruit? How often? List the fruits you like and do NOT like?

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Do you eat vegetables? How often? List the vegetables you like and do NOT like?

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How would you describe your current stress level?

Low: 1-3

Moderate: 4-6

High: 7-9

Profound: 10

What stress-reduction and exercise activities do you engage in?

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How many hours do you sleep per day?

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Do you smoke? If so, how much?

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Is there anything else you would like to share to better help our working together?

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