Client Information for Treatment |
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Employer:
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Occupation: *
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If Yes, when? *
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3) What would you like to achieve from your treatment today? *
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4) Which of the following best describes your skin type?*
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5) What areas of concern do you have regarding your Skin? * |
Blackheads/whiteheads |
Breakouts/acne |
Broken capillaries |
Dehydrated |
Dull/dry skin |
Excessive oil/shine |
Flaky skin |
Redness/ruddiness |
Rosacea |
Sun damage |
Sun spot/liver spot/brown spot |
Other |
Uneven skin tone |
Wrinkles/fine lines |
If Other:
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6) If any, what areas of concern do you have regarding your Eyes? |
dark circles |
dehydrated |
puffiness |
wrinkles |
Other |
If Other:
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7) If any, what areas of concern do you have regarding your Lips? |
dehydrated |
cracked/chapped lips |
Other |
If Other:
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8) What skincare products are you currently using on your face? * |
Facial Cleanser |
Facial Scrub |
Toner/Astringent |
Serum |
Eye Cream |
Day Moisturizer |
Night Cream |
Mask |
Shower Gel |
Soap |
Sun Screen |
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If Yes, What professional brand are you currently using? *
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10) Do you use any of the following on your skin? (Vitamin A derivative products) |
Adapalene Hydroxyl Acid |
Alpha Hydroxy Acid |
Deferin |
Glycolic Acid |
Renova |
Retin-A |
Retinol |
Salicylic Acid |
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If Yes, Please specify:
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12) What SPF do you use on your face?
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How often/when?
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13) What SPF do you use on your body?
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How often/when?
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14) How frequently are you exposed to the sun or use a tanning bed?*
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If Yes, How often? *
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Yes, check all that apply. |
Shaving |
Waxing |
Electrolysis |
Tweezing |
Stringing |
Depilatories |
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20) What is your current shaving system? |
Wet Shave |
Electric |
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Please use this space to complete answers where space was insufficient. (Please include the number of the question)
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Contact, Future Appointments & Referrals: |
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If Family, Friend, Co-Worker or Other- Please list full name *
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HEALTH HISTORY |
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Yes, explain:
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Name of Physician: *
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Physician Phone:
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2) List all medications you take regularly: *
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3) List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:
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Yes, when?
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Which drug?
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5) Have you had any of these health conditions in the past or present? Check all that apply. |
Any active infection |
Arthritis |
Asthma |
Blood clotting abnormalities |
Cancer |
Diabetes |
Eczema |
Epilepsy |
Fever blisters |
Frequent cold sores |
Headaches (chronic) |
Heart condition |
Hepatitis |
Herpes |
High blood pressure |
HIV/AIDS |
Hormone imbalance |
Hysterectomy |
Immune disorders |
Insomnia |
Keloid scarring |
Lupus |
Metal bone pins or plates |
Migraines |
Phlebitis, blood clots, poor circulation |
Psychological treatment |
Seizure disorder |
Skin disease/skin lesions |
Spinal injury |
Systemic disease |
Thyroid condition |
Varicose veins |
Yes, explain:
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Yes, explain: *
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Yes, explain:
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If Yes, what and when: *
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If yes, where on your person?
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Yes, specify:
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List your daily consumption of Water: *
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List your daily consumption of Caffeine: *
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List your daily consumption of Alcohol: *
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If Yes, How many days/Hours do you exercise? *
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18) How many hours do you typically sleep each night? *
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20) What is your stress level?*
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22) Have you ever had an allergic reaction to any of the following? (Please check any that apply) |
AHAs |
Animals |
Cosmetics |
Dairy Products |
Food |
Fragrance |
Iodine |
Latex Drugs |
Medicine |
Pollen |
Shellfish |
Sunscreens |
Other |
If Other, please state:
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23) Have you ever had an adverse reaction after using any skin care product? (Please check any that apply) |
Rash |
Irritation |
Peeling |
Sun Senstitivity |
Breakout |
If yes, please explain:
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Female Clients Only |
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Yes, specify:
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If so, what and when?
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Yes, specify:
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Please use this space to complete answers where space was insufficient. (Please include the number of the question)
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I understand, have read 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 or providing misinformation may result in contraindications and/or allergic reaction, irritation to the skin from treatments received. I am aware that it is my responsibility to inform the esthetician/skin care professional of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release Beauty and the Blend by Raylene/Raylene Davis and/or skin care professional from liability and assume full responsibility thereof.
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