QUALIFYING YOUR CLIENT
SKIN CARE HISTORY QUESTIONNAIRE
Please answer the following questions so that I may have a better understanding of your general health
and lifestyle, thereby enabling me to accurately analyze and assess your skin care needs.
First
/
Date
Name (please print clearly)
Name
/
Date of Birth
Last
/
M.I.
/
Street Address
City
State
Home Phone
(
Zip Code
E-Mail Address
)
Please check if presently using any of the following? (please all that apply)
❑ Accutane
❑ Glycolic Acid/Alpha Hydroxy Acid ❑ Topical Vitamin C
❑ Hydroquinone ❑ Retinoid (Vitamin A derivatives) i.e. Retin A, Renova, Differin
Which conditions do you want to improve (please all that apply)
❑ Hyperpigmentation (Brown Spots)
❑ Acne/Acne Scarring
❑ Fine Lines & Wrinkles ❑ Age Spots ❑ Surgical Facial Scars
Have you ever had an allergic reaction to any skin product or cosmetic?
❑ Sun Damage
❑ Other:
❑ Yes
❑ Enlarged Pores
❑ No
FEMALE CLIENTS
Are you on hormone replacement therapy?
Are you presently taking birth control pills?
Are you pregnant or planning to be?
❑ Yes
❑ Yes
❑ Yes
❑ No
❑ No
❑ No
Do you use a sunscreen/sun block?
Do you sunbathe or participate in outdoor activities?
❑ Yes
❑ Yes
❑ No
❑ No
Do you have or have ever had acne?
Are you using or have ever used any medications for acne?
Name of medication
❑ Yes
❑ Yes
❑ No
❑ No
Have you seen a Dermatologist in the past year?
If yes, list doctors name and reason for visit
❑ Yes
❑ No
Are you presently under a doctor’s care?
What medications do you take on a regular basis?
❑ Yes
❑ No
Have you ever had Herpes (cold sores)?
Have you ever been treated with Zovirax or any medication for Herpes?
❑ Yes
❑ Yes
❑ No
❑ No
ALL CLIENTS
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© 2009 Rhonda Allison Clinical Enterprises
© 2009 Rhonda Allison Clinical Enterprises
QUALIFYING YOUR CLIENT
SKIN CARE HISTORY QUESTIONNAIRE
Do you have Epilepsy or Diabetes?
❑ Yes
❑ No
If yes, you will be treated only with a doctors release!
Are you presently under a physicians care for any reason?
Explain
Do you use Biore or snore strips?
❑ Yes
❑ No
(please all that apply)
❑ Skin Cancer ❑ Dermatitis
❑ Keloid Scarring
❑ Hepatitis
❑ Other (Specify)
❑ No
❑ No
Are you allergic to Iodine or Seaweed?
Do you smoke?
Do you take nutritional supplements?
Are you on a diet?
Do you exercise?
Do you wear contact lenses?
Have you had skin treatments (facials) before?
Are you currently having facials?
Have you had electrolysis or waxing in the past week?
Do you have those services done?
Have you had permanent cosmetics?
If yes, where?
How is your general health?
❑ No
❑ No
Have you had any of the following?
❑ Yes
❑ Cosmetic Surgery
❑ Botox Injections
❑ Laser Resurfacing
❑ Chemical Peels
Are you allergic to aspirin?
❑ Yes
Do you have any other allergies? ❑ Yes
If yes, list:
❑ Yes
❑ Excellent
❑ Yes
❑ Yes
❑ Yes
❑ Yes
❑ Yes
❑ Yes
❑ Yes
❑ Yes
❑ Yes
❑ Yes
❑ Good
❑ Fair
❑ Yes
❑ No
❑ No
❑ No
❑ No
❑ No
❑ No
❑ No
❑ No
❑ No
❑ No
❑ No
❑ Poor
What skin care products are you currently using?
What is it about your skin you would like to change?
Is there any other information I should know before beginning your treatment?
Client
Signature
Copyright © 2009 Rhonda Allison Clinical Enterprises, Inc.
© 2009 Rhonda Allison Clinical Enterprises
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