Download Client Questionnaire

Skinplicity of Cary
Date_______/_________/20____ Email____________________@___________.________ (for communication & newsletter only)
Name____________________________________________________________________________________
Full Address____________________________________________City________________ZIP_____________
Phone - Home________________________________ Cell__________________________________________
DOB_______/_______/______
Contact Lenses? Y / N
Anniversary______/_______ Occupation____________________________
Are you having: Regular Periods / Peri-Menopausal / Menopausal (circle)
Chief Concerns/Skin Issues____________________________________________________________________________
Is Your Skin Sensitive__________From?_________________________________________________________________
List ALL Health conditions & Allergies __________________________________________________________________
__________________________________________________Do you get/have Fever Blisters/Herpes? Yes / No
What results do you expect from prof’l skincare services___________________________________________________
Facial homecare routine_____________________________________________________________________________
ALL Medications/Vitamins/Supplements/Hormones (HRT), Birth Control______________________________________
________________________________________________________________________________________________
 Using/have-used (Prescription or OTC): Benzoyl Peroxide/Accutane /Renova/Tazorac/Retin A/Other (circle)
Caffeine intake (daily/cups)_________H2O_________oz. Alcohol__________
Do you crave sugar? Y / N
Dermatologist name and city______________________________________________ Last exam__________________
Dermatologist’s Treatments and Findings_______________________________________________________________
History of childhood-early adult sunburn/tanning/Skin CA/ Family HX ________________________________________
Smoker/Ex-smoker___________yrs. Stress Level____________________ Hours of sleep nightly___________
Are you pregnant, lactating, planning to become pregnant? (circle)
Last Facial______/______/______ Treatment(s) received__________________________________________________
I have read, understand, and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes
any previous verbal or written disclosures. I understand that withholding information, providing misinformation and/or non-compliance, may
result in contraindications and/or irritation to the skin.
The treatments I receive here are voluntary and I release this institution and/or skin care professional from any liability and assume full
responsibility thereof.
Client Signature:
______________________________________________Date_____/_____/_____
Your privacy is respected. All information is solely for internal use, and is kept strictly confidential.