Contact detail

Name:


Address:



Telephone:



Email:




Age:
Under 21 21 - 30 31 - 40 41 - 50 51 - 60 65 +



Your health

Within the last year, have you been under a dermatologist or physician's care?
Yes No         



Within the last nine months, have you undergone any surgery?
Yes No     


specify:



Have you had any health problems in the past or present?
Yes


List any medications, supplements, vitamins, diuretics, slimming tablets etc. that you take regularly





Do you smoke?
Yes No


Do you exercise regularly?
Yes No


Do you follow a restricted diet?
Yes

Do you wear contact lenses?
Yes No


Do you have any metal implants or a pacemaker?
Yes


Your skin


What temperature do you cleanse with?
ColdWarm Hot


Do you have any special skin problems pertaining to your face or body?
Yes    No   

                                                                                                 Specify:


What skin products are you using?                Face








                                                                              
                                                                              Body

Soap
Cleanser
Toner
Moisturizer
Masque
Exfoliator
Eye products

Soap
Shower gel
Scrubs
Oil
Body moisturizer
Depilatory products
Self tanners



Exfoliation history


Have you had any chemical peels, microdermabrasion, or any resurfacing treatments?
Yes No     


                                                                                            In the last month? Yes No


Do you use Accutane, Retin A, Renova, Adapalene or any other prescription skin products?
Yes No   


                                                                                            In the last 3 months 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)
                                                                                                


Moisture hydration


How much water do you consume daily?


How much alcoholic beverages do you
consume weekly?



Do you ever experience  these conditions?
Flakiness
Tightness
Obvious dryness 

What spf sunscreen do you use on your face?


Do you sunbathe or use tanning beds?
Yes No



Capillary activity


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


Oil secretion


Do you ever experience oily shine during the day?
Yes
No
Occasionally


Do you ever experience skin breakouts?
Yes
No
Occasionally


Nerve activity


Do you drink more than 4 caffeinated beverages daily? (coffee, tea, soft drinks)
Yes
No


Do you ever experience a burning, itching sensation on your skin?
Yes
No


What is your pain threshold?
High
Medium
Low


Have you ever experienced claustrophobia?
Yes
No


What type of massage pressure do you prefer?
Light
Medium
Firm


Have you ever had a reaction to the following?
Cosmetics
Medicine
Iodine
Pollen
Food
Hydroxy acids
Animals
Fragrance
Sunscreens
Other


Female clients only


Are you talking oral contraception?
Yes No


Are you pregnant or trying to become pregnant?
Yes No


Are you lactating?
Yes No



Male clients only


What is your current shaving system?



Do you experience irritation when shaving?
Yes


Do you experience ingrown hairs?
Yes No



Confirmation and signature


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 treatment.

Clients name: