Skin Evaluation Form (Confidential)Client:(Required)Address:City/State:Zip:Date: MM slash DD slash YYYY Phone:(Required)E-mail:(Required) *Your phone number will be used for private messages only (confirming appointments, after-procedure follow-up calls, procedure fees, instructions for product pick-up, etc.).Please fill in the following description of your facial complexion. This information is necessary for us to design a customized skin care program for you. What type of skin do you have? Normal to Dry Normal to Oily Very Oily Very Dry Do you tan? Easily Tan Burn then Tan Burn Any chronic skin disorders? Fever Blisters Psoriasis Melasma/Hyperpigmentation Dermatitis Rosacea Other OtherWhat medications do you take?Do they make you photo-sensitive? Yes No List any medications or cosmetic ingredients you are allergic to:Please indicate if you are using any of the following:Retin-A Yes No Renova Yes No what strength?How long?what strength?How long?Accutane Yes No Valtrex/Zovirax Yes No Oral/topical Antibiotics Yes No Tetracycline Yes No Oral Contraceptives Yes No Do you have a hormone imbalance? Yes No Do you have any facial scarring? Yes No Have you had any facial surgery? Yes No what facial region?what facial region?Any prior cosmetic peels? Yes No Salon TCA AHA Other Any history of skin cancer? Yes No Date MM slash DD slash YYYY Are you pregnant? Yes No Planning Breast Feeding? Yes No Have you had facial hair removal? Yes No Yes Wax Electrolysis Laser Date MM slash DD slash YYYY Check any skin conditions you are concerned about Sun Damage Brown Spots (splotchy or uneven skin color) Freckles Upper Lip Lines Wrinkles Blackheads Whiteheads Milia Hard Bumps Under Skin Clogged Pores Acne Pimples/Breakouts Visible Facial Spider Veins/Capillaries Other Concerns Upper Lip Lines Fine Deep Wrinkles Fine Deep Pimples/Breakouts Sometimes Frequently Other Concerns:Office NotesOffice NotesOffice NotesOffice NotesOffice NotesOffice NotesOffice NotesOffice NotesOffice NotesOffice NotesOffice NotesOffice NotesOffice NotesOffice NotesPlease check the products you are currently using and list the brand name Cleanser Soap Night Moisturizer Antioxidants Exfoliant Facial Mask Toner Day Moisturizer Eye Cream Skin Lightener Sunscreen At Home Peels CommentCommentCommentCommentCommentCommentCommentCommentCommentCommentCommentCommentI understand that the services offered are not a substitute for medical care, and any information provided by the aesthetician is for educational purposes only and not diagnostically prescriptive in nature. I understand that the information herein is to aid the aesthetician in giving better service and is completely confidential.Client Signature:Date: MM slash DD slash YYYY
