Skin Health Questionnaire NameDateAddressCityStateZip CodeEmail Birth Date MM slash DD slash YYYY CellphoneOther PhoneOccupationCurrent Skin CareMost Recent FacialMonth/YearMost Recent WaxingMonth/YearHow do you feel about your skin?1 Poor Р10 Fantastic 1 2 3 4 5 6 7 8 9 10 Skin ConditionsCheck all that apply None Wrinkles/Fine Lines Pigmentation Redness Rosacea Dry/Rough Acne/Oily Products Used DailyCheck all that apply Cleanser Soap Exfoliator Toner Moisturizer Sun Protection Other Treatment LifestyleDo you use tanning booths/beds? Yes No Do you wax or use depilatories, electrolysis, or lasers for hair removal? Yes No Do you have Botox, Restylane, Juv̩derm or collagen injections? Yes No Last treatment?Are you using exfoliating acids (glycolics)? Yes No Which ones? Retin A Retinol Glycolic Other OtherDo you sunburn easily? Yes No Date of Last SunburnDo you smoke? Yes No How many ounces of water do you drink daily?Stress level High Average Low Health HistoryList any allergiesList current oral/topical medications:Have you recently had facial surgery or laser resurfacing? Yes No Are you currently under the care of a dermatologist? Yes No If yes, please list name/locationHealth ConditionsCheck all that apply Diabetes Psoriasis Herpes Varicose Veins Chemotherapy Epilepsy Phlebitis Eczema Pacemaker Cancer Retin A Sunburn Hormone Pills Accutane Contact lenses Open Sores Pregnant Metal implants Other health conditions of which we should be aware?Skin Retreat products and services are considered safe and involve minimal risk to our clients. Each Skin Retreat services involves applying a carefully selected product to your skin. Each products has been tested on humans to ensure it is safe. However, there is always a small risk of a mild reaction with any product. I UNDERSTAND AND VOLUNTARILY ACCEPT ANY RISKS ASSOCIATED WITH MY SERVICES AND THE USE OF THE SKIN RETREAT FACILILTY. I AGREE TO HOLD SKIN RETREAT HARMLESS FOR ANY INJURY, LOSS, CLAIMS AND DAMAGES, INCLUDING, WITHOUT LIMITATION, PERSONAL, BODILY, OR MENTAL INJURY, ECONOMIC LOSS, OR ANY DAMAGE TO ME RESULTING FROM MY RECEIPT OR USE OF THE SERVICES OR THE FACILITIES OF THE SPA.I certify that I have given an honest and complete evaluation of my present physical condition.(Initial)I will immediately notify my esthetician of any changes in my physical condition.(Initial)I understand that I may experience temporary redness or a cleansing breakout following my treatment.(Initial)Guest SignatureDate Signed MM slash DD slash YYYY Parent/Guardian Signature(if guest is a minor)Date Signed MM slash DD slash YYYY
