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New Client Treatment/Health History Form

 

We want to give you the best treatment possible with results your sure to love.

___________________________________________________________

It's important to fill out the digital form completely while answering all questions to the best of your ability.  This will help us to avoid any possible contraindacations, allergic reactions etc...

If something does not apply to you, please indacate with a "N/A" in the available space box provided.

________________________________________________________________

We look forward to seeing you at your appointment :)

I hereby consent to and authorize Raylene Davis on behalf of Beauty and the Blend By Raylene to perform treatment/treatments.

I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of this treatment has been explained to me, along with the risks and hazards involved, by Raylene Davis.

Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost.

I have read and understand the post-treatment home care instructions. I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult Raylene Davis immediately.

I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs, vitamins/supplements or products I am currently ingesting or using topically.

I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold Raylene Davis the esthetician or Beauty and the Blend by Raylene, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment/s performed today.

Rescheduling/Cancellation Policy

We understand that unanticipated events happen occasionally in everyone’s life. In our desire to be effective and fair to all clients, the following policies are honored:

ARRIVAL TIME
Please aim to arrive 10 minutes before scheduled appointment time.  If a client arrives after their scheduled appointment time; Depending upon how late a client arrives, we will then determine if there is enough time remaining to start treatment. If treatment is shortened due to client's late arrival, client will still be charged the full cost of the treatment. Out of respect and consideration to us and other customers, please plan accordingly.

RESCHEDULE/CANCEL
24 hour notice is required to reschedule or cancel a booked appointment, This allows the opportunity for someone else to schedule an appointment. If clients are unable to give us 24 hours advance notice, they may be charged the full amount of their appointment at our discretion. This amount will be paid with the card on file and/or prior to their next scheduled appointment. Exception in cases of infectious or illness as described below:

ILLNESS
If you, or another person in your household, has an infectious or contagious illness, please contact us as soon as possible to reschedule your appointment for a later date. There is no penalty in this case, for your safety and that of our other clients.

NO-SHOW

Clients who either forgets or consciously chooses to forgo their appointment for whatever reason will be considered a “no-show.” They will be charged the full amount for their “missed” appointment paid with the card on file and/or prior to their next scheduled appointment.

I agree to the policies described above.

 

Today's Date: June 4, 2020

 

First Client's Name

First Name*

Middle Name

Last Name*

Phone*
First Client's Date of Birth*
First Client's digital form for treatment

Client Information for Treatment 

Single:*
No
Yes
Married:*
No
Yes

Employer:

Occupation: *
1) Does your job require that you work outdoors?*
No
Yes
2) Have you ever had a facial treatment before?*
No
Yes

If Yes, when? *

3) What would you like to achieve from your treatment today? *
4) Which of the following best describes your skin type?*
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:
6) If any, what areas of concern do you have regarding your Eyes?
dark circles
dehydrated
puffiness
wrinkles
Other

If Other:
7) If any, what areas of concern do you have regarding your Lips?
dehydrated
cracked/chapped lips
Other

If Other:

Skincare Information

8) What skincare products are you currently using on your face? *
Day Moisturizer
Eye Cream
Facial Cleanser
Facial Scrub
Mask
Night Cream
Serum
Shower Gel
Soap
Sun Screen
Toner/Astringent
9) Are you currently using a prescribed/recommended professional skincare system from a Dermatologist or Skin Care Professional?*
No
Yes

If Yes, What professional brand are you currently using? *
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
11) Have you used any of these Vitamin A derivative products in the last 3 months?*
No
Yes

If Yes, Please specify:

12) What SPF do you use on your face?

How often/when?

13) What SPF do you use on your body?

How often/when?
14) How frequently are you exposed to the sun or use a tanning bed?*
15) Have you been exposed to the sun or used a tanning bed in the last 48 hours?*
No
Yes
16) Have you had any recent tanning bed or sun exposure that changed the color of your skin?*
No
Yes
17) Have you recently used any self-tanning lotions, creams or treatments?*
No
Yes
18) Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes
Within the last month?*
No
Yes
19) Have you used any of the following hair removal methods in the past six weeks?*
No
Yes

If Yes, How often? *
Yes, check all that apply.
Shaving
Waxing
Electrolysis
Tweezing
Stringing
Depilatories

Male Clients Only: 

20) What is your current shaving system?
Wet Shave
Electric
21) Do you experience irritation from shaving?*
No
Yes
Ingrown hairs?*
No
Yes

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

Contact, Future Appointments & Referrals: 

May I call/text you at your home, work or cell phone number you provided to confirm future appointments?*
No
Yes
May I contact you via text/mail/email about future monthly specials, new treatments, and news?*
No
Yes
We love referrals! Did anyone refer you to us? How did you hear about us?*
Facebook
Friend/Family/Co-Worker
Google Business
Groupon
Instagram
Sola Salon Studios Website
Walked by/Grabbed Business Card
Website/Search Engine
Yelp
Other

If Family, Friend, Co-Worker or Other- Please list full name *


HEALTH HISTORY

1) Have you been under the care of a physician, dermatologist or other medical professional within the past year?*
No
Yes

Yes, explain:

Name of Physician: *

Physician Phone:

2) List all medications you take regularly: *

3) List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:
4) Have you used an acne medication?*
No
Yes

Yes, when?

Which drug?
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:
6) Any skin cancer (past or present)?*
No
Yes

Yes, explain: *
7) Any recent surgery, including plastic surgery?*
No
Yes

Yes, explain:
8) Have you received Botox, Restylane or Collagen injections?*
No
Yes

If Yes, what and when: *
9) Do you have any metal implants or wear a pacemaker?*
No
Yes
10) Do you wear contact lenses?*
No
Yes
11) Do you suffer from sinus problems?*
No
Yes
12) Have you had any piercings, tattoos, or permanent cosmetics?*
No
Yes

If yes, where on your person?
13) Do you form thick or raised scars from cuts or burns?*
No
Yes
14) Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
No
Yes
15) Do you follow a restricted diet?*
No
Yes

Yes, specify:

List your daily consumption of Water: *

List your daily consumption of Caffeine: *

List your daily consumption of Alcohol: *
16) Do you smoke?*
No
Yes
17) Do you follow a regular exercise program?*
No
Yes

If Yes, How many days/Hours do you exercise? *

18) How many hours do you typically sleep each night? *
19) Do you experience any problems sleeping?*
No
Yes
20) What is your stress level?*
21) Have you ever experienced claustrophobia?*
No
Yes
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:
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:

Female Clients Only

24) Are you taking oral contraceptives?*
No
Yes

Yes, specify:
25) Any recent changes to or from your contraceptive treatment?*
No
Yes

If so, what and when?
26) Are you pregnant or trying to become pregnant?*
No
Yes
27) Are you lactating?*
No
Yes
28) Any menopause problems?*
No
Yes

Yes, specify:

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

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. 


First Client's Signature*
Second Client's Name

First Name*

Middle Name

Last Name*
Second Client's Date of Birth*
Second Client's digital form for treatment

Client Information for Treatment 

Single:*
No
Yes
Married:*
No
Yes

Employer:

Occupation: *
1) Does your job require that you work outdoors?*
No
Yes
2) Have you ever had a facial treatment before?*
No
Yes

If Yes, when? *

3) What would you like to achieve from your treatment today? *
4) Which of the following best describes your skin type?*
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:
6) If any, what areas of concern do you have regarding your Eyes?
dark circles
dehydrated
puffiness
wrinkles
Other

If Other:
7) If any, what areas of concern do you have regarding your Lips?
dehydrated
cracked/chapped lips
Other

If Other:

Skincare Information

8) What skincare products are you currently using on your face? *
Day Moisturizer
Eye Cream
Facial Cleanser
Facial Scrub
Mask
Night Cream
Serum
Shower Gel
Soap
Sun Screen
Toner/Astringent
9) Are you currently using a prescribed/recommended professional skincare system from a Dermatologist or Skin Care Professional?*
No
Yes

If Yes, What professional brand are you currently using? *
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
11) Have you used any of these Vitamin A derivative products in the last 3 months?*
No
Yes

If Yes, Please specify:

12) What SPF do you use on your face?

How often/when?

13) What SPF do you use on your body?

How often/when?
14) How frequently are you exposed to the sun or use a tanning bed?*
15) Have you been exposed to the sun or used a tanning bed in the last 48 hours?*
No
Yes
16) Have you had any recent tanning bed or sun exposure that changed the color of your skin?*
No
Yes
17) Have you recently used any self-tanning lotions, creams or treatments?*
No
Yes
18) Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes
Within the last month?*
No
Yes
19) Have you used any of the following hair removal methods in the past six weeks?*
No
Yes

If Yes, How often? *
Yes, check all that apply.
Shaving
Waxing
Electrolysis
Tweezing
Stringing
Depilatories

Male Clients Only: 

20) What is your current shaving system?
Wet Shave
Electric
21) Do you experience irritation from shaving?*
No
Yes
Ingrown hairs?*
No
Yes

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

Contact, Future Appointments & Referrals: 

May I call/text you at your home, work or cell phone number you provided to confirm future appointments?*
No
Yes
May I contact you via text/mail/email about future monthly specials, new treatments, and news?*
No
Yes
We love referrals! Did anyone refer you to us? How did you hear about us?*
Facebook
Friend/Family/Co-Worker
Google Business
Groupon
Instagram
Sola Salon Studios Website
Walked by/Grabbed Business Card
Website/Search Engine
Yelp
Other

If Family, Friend, Co-Worker or Other- Please list full name *


HEALTH HISTORY

1) Have you been under the care of a physician, dermatologist or other medical professional within the past year?*
No
Yes

Yes, explain:

Name of Physician: *

Physician Phone:

2) List all medications you take regularly: *

3) List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:
4) Have you used an acne medication?*
No
Yes

Yes, when?

Which drug?
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:
6) Any skin cancer (past or present)?*
No
Yes

Yes, explain: *
7) Any recent surgery, including plastic surgery?*
No
Yes

Yes, explain:
8) Have you received Botox, Restylane or Collagen injections?*
No
Yes

If Yes, what and when: *
9) Do you have any metal implants or wear a pacemaker?*
No
Yes
10) Do you wear contact lenses?*
No
Yes
11) Do you suffer from sinus problems?*
No
Yes
12) Have you had any piercings, tattoos, or permanent cosmetics?*
No
Yes

If yes, where on your person?
13) Do you form thick or raised scars from cuts or burns?*
No
Yes
14) Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
No
Yes
15) Do you follow a restricted diet?*
No
Yes

Yes, specify:

List your daily consumption of Water: *

List your daily consumption of Caffeine: *

List your daily consumption of Alcohol: *
16) Do you smoke?*
No
Yes
17) Do you follow a regular exercise program?*
No
Yes

If Yes, How many days/Hours do you exercise? *

18) How many hours do you typically sleep each night? *
19) Do you experience any problems sleeping?*
No
Yes
20) What is your stress level?*
21) Have you ever experienced claustrophobia?*
No
Yes
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:
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:

Female Clients Only

24) Are you taking oral contraceptives?*
No
Yes

Yes, specify:
25) Any recent changes to or from your contraceptive treatment?*
No
Yes

If so, what and when?
26) Are you pregnant or trying to become pregnant?*
No
Yes
27) Are you lactating?*
No
Yes
28) Any menopause problems?*
No
Yes

Yes, specify:

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

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. 


Third Client's Name

First Name*

Middle Name

Last Name*
Third Client's Date of Birth*
Third Client's digital form for treatment

Client Information for Treatment 

Single:*
No
Yes
Married:*
No
Yes

Employer:

Occupation: *
1) Does your job require that you work outdoors?*
No
Yes
2) Have you ever had a facial treatment before?*
No
Yes

If Yes, when? *

3) What would you like to achieve from your treatment today? *
4) Which of the following best describes your skin type?*
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:
6) If any, what areas of concern do you have regarding your Eyes?
dark circles
dehydrated
puffiness
wrinkles
Other

If Other:
7) If any, what areas of concern do you have regarding your Lips?
dehydrated
cracked/chapped lips
Other

If Other:

Skincare Information

8) What skincare products are you currently using on your face? *
Day Moisturizer
Eye Cream
Facial Cleanser
Facial Scrub
Mask
Night Cream
Serum
Shower Gel
Soap
Sun Screen
Toner/Astringent
9) Are you currently using a prescribed/recommended professional skincare system from a Dermatologist or Skin Care Professional?*
No
Yes

If Yes, What professional brand are you currently using? *
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
11) Have you used any of these Vitamin A derivative products in the last 3 months?*
No
Yes

If Yes, Please specify:

12) What SPF do you use on your face?

How often/when?

13) What SPF do you use on your body?

How often/when?
14) How frequently are you exposed to the sun or use a tanning bed?*
15) Have you been exposed to the sun or used a tanning bed in the last 48 hours?*
No
Yes
16) Have you had any recent tanning bed or sun exposure that changed the color of your skin?*
No
Yes
17) Have you recently used any self-tanning lotions, creams or treatments?*
No
Yes
18) Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes
Within the last month?*
No
Yes
19) Have you used any of the following hair removal methods in the past six weeks?*
No
Yes

If Yes, How often? *
Yes, check all that apply.
Shaving
Waxing
Electrolysis
Tweezing
Stringing
Depilatories

Male Clients Only: 

20) What is your current shaving system?
Wet Shave
Electric
21) Do you experience irritation from shaving?*
No
Yes
Ingrown hairs?*
No
Yes

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

Contact, Future Appointments & Referrals: 

May I call/text you at your home, work or cell phone number you provided to confirm future appointments?*
No
Yes
May I contact you via text/mail/email about future monthly specials, new treatments, and news?*
No
Yes
We love referrals! Did anyone refer you to us? How did you hear about us?*
Facebook
Friend/Family/Co-Worker
Google Business
Groupon
Instagram
Sola Salon Studios Website
Walked by/Grabbed Business Card
Website/Search Engine
Yelp
Other

If Family, Friend, Co-Worker or Other- Please list full name *


HEALTH HISTORY

1) Have you been under the care of a physician, dermatologist or other medical professional within the past year?*
No
Yes

Yes, explain:

Name of Physician: *

Physician Phone:

2) List all medications you take regularly: *

3) List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:
4) Have you used an acne medication?*
No
Yes

Yes, when?

Which drug?
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:
6) Any skin cancer (past or present)?*
No
Yes

Yes, explain: *
7) Any recent surgery, including plastic surgery?*
No
Yes

Yes, explain:
8) Have you received Botox, Restylane or Collagen injections?*
No
Yes

If Yes, what and when: *
9) Do you have any metal implants or wear a pacemaker?*
No
Yes
10) Do you wear contact lenses?*
No
Yes
11) Do you suffer from sinus problems?*
No
Yes
12) Have you had any piercings, tattoos, or permanent cosmetics?*
No
Yes

If yes, where on your person?
13) Do you form thick or raised scars from cuts or burns?*
No
Yes
14) Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
No
Yes
15) Do you follow a restricted diet?*
No
Yes

Yes, specify:

List your daily consumption of Water: *

List your daily consumption of Caffeine: *

List your daily consumption of Alcohol: *
16) Do you smoke?*
No
Yes
17) Do you follow a regular exercise program?*
No
Yes

If Yes, How many days/Hours do you exercise? *

18) How many hours do you typically sleep each night? *
19) Do you experience any problems sleeping?*
No
Yes
20) What is your stress level?*
21) Have you ever experienced claustrophobia?*
No
Yes
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:
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:

Female Clients Only

24) Are you taking oral contraceptives?*
No
Yes

Yes, specify:
25) Any recent changes to or from your contraceptive treatment?*
No
Yes

If so, what and when?
26) Are you pregnant or trying to become pregnant?*
No
Yes
27) Are you lactating?*
No
Yes
28) Any menopause problems?*
No
Yes

Yes, specify:

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

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. 


Fourth Client's Name

First Name*

Middle Name

Last Name*
Fourth Client's Date of Birth*
Fourth Client's digital form for treatment

Client Information for Treatment 

Single:*
No
Yes
Married:*
No
Yes

Employer:

Occupation: *
1) Does your job require that you work outdoors?*
No
Yes
2) Have you ever had a facial treatment before?*
No
Yes

If Yes, when? *

3) What would you like to achieve from your treatment today? *
4) Which of the following best describes your skin type?*
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:
6) If any, what areas of concern do you have regarding your Eyes?
dark circles
dehydrated
puffiness
wrinkles
Other

If Other:
7) If any, what areas of concern do you have regarding your Lips?
dehydrated
cracked/chapped lips
Other

If Other:

Skincare Information

8) What skincare products are you currently using on your face? *
Day Moisturizer
Eye Cream
Facial Cleanser
Facial Scrub
Mask
Night Cream
Serum
Shower Gel
Soap
Sun Screen
Toner/Astringent
9) Are you currently using a prescribed/recommended professional skincare system from a Dermatologist or Skin Care Professional?*
No
Yes

If Yes, What professional brand are you currently using? *
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
11) Have you used any of these Vitamin A derivative products in the last 3 months?*
No
Yes

If Yes, Please specify:

12) What SPF do you use on your face?

How often/when?

13) What SPF do you use on your body?

How often/when?
14) How frequently are you exposed to the sun or use a tanning bed?*
15) Have you been exposed to the sun or used a tanning bed in the last 48 hours?*
No
Yes
16) Have you had any recent tanning bed or sun exposure that changed the color of your skin?*
No
Yes
17) Have you recently used any self-tanning lotions, creams or treatments?*
No
Yes
18) Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes
Within the last month?*
No
Yes
19) Have you used any of the following hair removal methods in the past six weeks?*
No
Yes

If Yes, How often? *
Yes, check all that apply.
Shaving
Waxing
Electrolysis
Tweezing
Stringing
Depilatories

Male Clients Only: 

20) What is your current shaving system?
Wet Shave
Electric
21) Do you experience irritation from shaving?*
No
Yes
Ingrown hairs?*
No
Yes

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

Contact, Future Appointments & Referrals: 

May I call/text you at your home, work or cell phone number you provided to confirm future appointments?*
No
Yes
May I contact you via text/mail/email about future monthly specials, new treatments, and news?*
No
Yes
We love referrals! Did anyone refer you to us? How did you hear about us?*
Facebook
Friend/Family/Co-Worker
Google Business
Groupon
Instagram
Sola Salon Studios Website
Walked by/Grabbed Business Card
Website/Search Engine
Yelp
Other

If Family, Friend, Co-Worker or Other- Please list full name *


HEALTH HISTORY

1) Have you been under the care of a physician, dermatologist or other medical professional within the past year?*
No
Yes

Yes, explain:

Name of Physician: *

Physician Phone:

2) List all medications you take regularly: *

3) List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:
4) Have you used an acne medication?*
No
Yes

Yes, when?

Which drug?
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:
6) Any skin cancer (past or present)?*
No
Yes

Yes, explain: *
7) Any recent surgery, including plastic surgery?*
No
Yes

Yes, explain:
8) Have you received Botox, Restylane or Collagen injections?*
No
Yes

If Yes, what and when: *
9) Do you have any metal implants or wear a pacemaker?*
No
Yes
10) Do you wear contact lenses?*
No
Yes
11) Do you suffer from sinus problems?*
No
Yes
12) Have you had any piercings, tattoos, or permanent cosmetics?*
No
Yes

If yes, where on your person?
13) Do you form thick or raised scars from cuts or burns?*
No
Yes
14) Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
No
Yes
15) Do you follow a restricted diet?*
No
Yes

Yes, specify:

List your daily consumption of Water: *

List your daily consumption of Caffeine: *

List your daily consumption of Alcohol: *
16) Do you smoke?*
No
Yes
17) Do you follow a regular exercise program?*
No
Yes

If Yes, How many days/Hours do you exercise? *

18) How many hours do you typically sleep each night? *
19) Do you experience any problems sleeping?*
No
Yes
20) What is your stress level?*
21) Have you ever experienced claustrophobia?*
No
Yes
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:
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:

Female Clients Only

24) Are you taking oral contraceptives?*
No
Yes

Yes, specify:
25) Any recent changes to or from your contraceptive treatment?*
No
Yes

If so, what and when?
26) Are you pregnant or trying to become pregnant?*
No
Yes
27) Are you lactating?*
No
Yes
28) Any menopause problems?*
No
Yes

Yes, specify:

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

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. 


Fifth Client's Name

First Name*

Middle Name

Last Name*
Fifth Client's Date of Birth*
Fifth Client's digital form for treatment

Client Information for Treatment 

Single:*
No
Yes
Married:*
No
Yes

Employer:

Occupation: *
1) Does your job require that you work outdoors?*
No
Yes
2) Have you ever had a facial treatment before?*
No
Yes

If Yes, when? *

3) What would you like to achieve from your treatment today? *
4) Which of the following best describes your skin type?*
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:
6) If any, what areas of concern do you have regarding your Eyes?
dark circles
dehydrated
puffiness
wrinkles
Other

If Other:
7) If any, what areas of concern do you have regarding your Lips?
dehydrated
cracked/chapped lips
Other

If Other:

Skincare Information

8) What skincare products are you currently using on your face? *
Day Moisturizer
Eye Cream
Facial Cleanser
Facial Scrub
Mask
Night Cream
Serum
Shower Gel
Soap
Sun Screen
Toner/Astringent
9) Are you currently using a prescribed/recommended professional skincare system from a Dermatologist or Skin Care Professional?*
No
Yes

If Yes, What professional brand are you currently using? *
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
11) Have you used any of these Vitamin A derivative products in the last 3 months?*
No
Yes

If Yes, Please specify:

12) What SPF do you use on your face?

How often/when?

13) What SPF do you use on your body?

How often/when?
14) How frequently are you exposed to the sun or use a tanning bed?*
15) Have you been exposed to the sun or used a tanning bed in the last 48 hours?*
No
Yes
16) Have you had any recent tanning bed or sun exposure that changed the color of your skin?*
No
Yes
17) Have you recently used any self-tanning lotions, creams or treatments?*
No
Yes
18) Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes
Within the last month?*
No
Yes
19) Have you used any of the following hair removal methods in the past six weeks?*
No
Yes

If Yes, How often? *
Yes, check all that apply.
Shaving
Waxing
Electrolysis
Tweezing
Stringing
Depilatories

Male Clients Only: 

20) What is your current shaving system?
Wet Shave
Electric
21) Do you experience irritation from shaving?*
No
Yes
Ingrown hairs?*
No
Yes

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

Contact, Future Appointments & Referrals: 

May I call/text you at your home, work or cell phone number you provided to confirm future appointments?*
No
Yes
May I contact you via text/mail/email about future monthly specials, new treatments, and news?*
No
Yes
We love referrals! Did anyone refer you to us? How did you hear about us?*
Facebook
Friend/Family/Co-Worker
Google Business
Groupon
Instagram
Sola Salon Studios Website
Walked by/Grabbed Business Card
Website/Search Engine
Yelp
Other

If Family, Friend, Co-Worker or Other- Please list full name *


HEALTH HISTORY

1) Have you been under the care of a physician, dermatologist or other medical professional within the past year?*
No
Yes

Yes, explain:

Name of Physician: *

Physician Phone:

2) List all medications you take regularly: *

3) List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:
4) Have you used an acne medication?*
No
Yes

Yes, when?

Which drug?
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:
6) Any skin cancer (past or present)?*
No
Yes

Yes, explain: *
7) Any recent surgery, including plastic surgery?*
No
Yes

Yes, explain:
8) Have you received Botox, Restylane or Collagen injections?*
No
Yes

If Yes, what and when: *
9) Do you have any metal implants or wear a pacemaker?*
No
Yes
10) Do you wear contact lenses?*
No
Yes
11) Do you suffer from sinus problems?*
No
Yes
12) Have you had any piercings, tattoos, or permanent cosmetics?*
No
Yes

If yes, where on your person?
13) Do you form thick or raised scars from cuts or burns?*
No
Yes
14) Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
No
Yes
15) Do you follow a restricted diet?*
No
Yes

Yes, specify:

List your daily consumption of Water: *

List your daily consumption of Caffeine: *

List your daily consumption of Alcohol: *
16) Do you smoke?*
No
Yes
17) Do you follow a regular exercise program?*
No
Yes

If Yes, How many days/Hours do you exercise? *

18) How many hours do you typically sleep each night? *
19) Do you experience any problems sleeping?*
No
Yes
20) What is your stress level?*
21) Have you ever experienced claustrophobia?*
No
Yes
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:
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:

Female Clients Only

24) Are you taking oral contraceptives?*
No
Yes

Yes, specify:
25) Any recent changes to or from your contraceptive treatment?*
No
Yes

If so, what and when?
26) Are you pregnant or trying to become pregnant?*
No
Yes
27) Are you lactating?*
No
Yes
28) Any menopause problems?*
No
Yes

Yes, specify:

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

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. 


Sixth Client's Name

First Name*

Middle Name

Last Name*
Sixth Client's Date of Birth*
Sixth Client's digital form for treatment

Client Information for Treatment 

Single:*
No
Yes
Married:*
No
Yes

Employer:

Occupation: *
1) Does your job require that you work outdoors?*
No
Yes
2) Have you ever had a facial treatment before?*
No
Yes

If Yes, when? *

3) What would you like to achieve from your treatment today? *
4) Which of the following best describes your skin type?*
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:
6) If any, what areas of concern do you have regarding your Eyes?
dark circles
dehydrated
puffiness
wrinkles
Other

If Other:
7) If any, what areas of concern do you have regarding your Lips?
dehydrated
cracked/chapped lips
Other

If Other:

Skincare Information

8) What skincare products are you currently using on your face? *
Day Moisturizer
Eye Cream
Facial Cleanser
Facial Scrub
Mask
Night Cream
Serum
Shower Gel
Soap
Sun Screen
Toner/Astringent
9) Are you currently using a prescribed/recommended professional skincare system from a Dermatologist or Skin Care Professional?*
No
Yes

If Yes, What professional brand are you currently using? *
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
11) Have you used any of these Vitamin A derivative products in the last 3 months?*
No
Yes

If Yes, Please specify:

12) What SPF do you use on your face?

How often/when?

13) What SPF do you use on your body?

How often/when?
14) How frequently are you exposed to the sun or use a tanning bed?*
15) Have you been exposed to the sun or used a tanning bed in the last 48 hours?*
No
Yes
16) Have you had any recent tanning bed or sun exposure that changed the color of your skin?*
No
Yes
17) Have you recently used any self-tanning lotions, creams or treatments?*
No
Yes
18) Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes
Within the last month?*
No
Yes
19) Have you used any of the following hair removal methods in the past six weeks?*
No
Yes

If Yes, How often? *
Yes, check all that apply.
Shaving
Waxing
Electrolysis
Tweezing
Stringing
Depilatories

Male Clients Only: 

20) What is your current shaving system?
Wet Shave
Electric
21) Do you experience irritation from shaving?*
No
Yes
Ingrown hairs?*
No
Yes

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

Contact, Future Appointments & Referrals: 

May I call/text you at your home, work or cell phone number you provided to confirm future appointments?*
No
Yes
May I contact you via text/mail/email about future monthly specials, new treatments, and news?*
No
Yes
We love referrals! Did anyone refer you to us? How did you hear about us?*
Facebook
Friend/Family/Co-Worker
Google Business
Groupon
Instagram
Sola Salon Studios Website
Walked by/Grabbed Business Card
Website/Search Engine
Yelp
Other

If Family, Friend, Co-Worker or Other- Please list full name *


HEALTH HISTORY

1) Have you been under the care of a physician, dermatologist or other medical professional within the past year?*
No
Yes

Yes, explain:

Name of Physician: *

Physician Phone:

2) List all medications you take regularly: *

3) List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:
4) Have you used an acne medication?*
No
Yes

Yes, when?

Which drug?
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:
6) Any skin cancer (past or present)?*
No
Yes

Yes, explain: *
7) Any recent surgery, including plastic surgery?*
No
Yes

Yes, explain:
8) Have you received Botox, Restylane or Collagen injections?*
No
Yes

If Yes, what and when: *
9) Do you have any metal implants or wear a pacemaker?*
No
Yes
10) Do you wear contact lenses?*
No
Yes
11) Do you suffer from sinus problems?*
No
Yes
12) Have you had any piercings, tattoos, or permanent cosmetics?*
No
Yes

If yes, where on your person?
13) Do you form thick or raised scars from cuts or burns?*
No
Yes
14) Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
No
Yes
15) Do you follow a restricted diet?*
No
Yes

Yes, specify:

List your daily consumption of Water: *

List your daily consumption of Caffeine: *

List your daily consumption of Alcohol: *
16) Do you smoke?*
No
Yes
17) Do you follow a regular exercise program?*
No
Yes

If Yes, How many days/Hours do you exercise? *

18) How many hours do you typically sleep each night? *
19) Do you experience any problems sleeping?*
No
Yes
20) What is your stress level?*
21) Have you ever experienced claustrophobia?*
No
Yes
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:
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:

Female Clients Only

24) Are you taking oral contraceptives?*
No
Yes

Yes, specify:
25) Any recent changes to or from your contraceptive treatment?*
No
Yes

If so, what and when?
26) Are you pregnant or trying to become pregnant?*
No
Yes
27) Are you lactating?*
No
Yes
28) Any menopause problems?*
No
Yes

Yes, specify:

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

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. 


Seventh Client's Name

First Name*

Middle Name

Last Name*
Seventh Client's Date of Birth*
Seventh Client's digital form for treatment

Client Information for Treatment 

Single:*
No
Yes
Married:*
No
Yes

Employer:

Occupation: *
1) Does your job require that you work outdoors?*
No
Yes
2) Have you ever had a facial treatment before?*
No
Yes

If Yes, when? *

3) What would you like to achieve from your treatment today? *
4) Which of the following best describes your skin type?*
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:
6) If any, what areas of concern do you have regarding your Eyes?
dark circles
dehydrated
puffiness
wrinkles
Other

If Other:
7) If any, what areas of concern do you have regarding your Lips?
dehydrated
cracked/chapped lips
Other

If Other:

Skincare Information

8) What skincare products are you currently using on your face? *
Day Moisturizer
Eye Cream
Facial Cleanser
Facial Scrub
Mask
Night Cream
Serum
Shower Gel
Soap
Sun Screen
Toner/Astringent
9) Are you currently using a prescribed/recommended professional skincare system from a Dermatologist or Skin Care Professional?*
No
Yes

If Yes, What professional brand are you currently using? *
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
11) Have you used any of these Vitamin A derivative products in the last 3 months?*
No
Yes

If Yes, Please specify:

12) What SPF do you use on your face?

How often/when?

13) What SPF do you use on your body?

How often/when?
14) How frequently are you exposed to the sun or use a tanning bed?*
15) Have you been exposed to the sun or used a tanning bed in the last 48 hours?*
No
Yes
16) Have you had any recent tanning bed or sun exposure that changed the color of your skin?*
No
Yes
17) Have you recently used any self-tanning lotions, creams or treatments?*
No
Yes
18) Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes
Within the last month?*
No
Yes
19) Have you used any of the following hair removal methods in the past six weeks?*
No
Yes

If Yes, How often? *
Yes, check all that apply.
Shaving
Waxing
Electrolysis
Tweezing
Stringing
Depilatories

Male Clients Only: 

20) What is your current shaving system?
Wet Shave
Electric
21) Do you experience irritation from shaving?*
No
Yes
Ingrown hairs?*
No
Yes

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

Contact, Future Appointments & Referrals: 

May I call/text you at your home, work or cell phone number you provided to confirm future appointments?*
No
Yes
May I contact you via text/mail/email about future monthly specials, new treatments, and news?*
No
Yes
We love referrals! Did anyone refer you to us? How did you hear about us?*
Facebook
Friend/Family/Co-Worker
Google Business
Groupon
Instagram
Sola Salon Studios Website
Walked by/Grabbed Business Card
Website/Search Engine
Yelp
Other

If Family, Friend, Co-Worker or Other- Please list full name *


HEALTH HISTORY

1) Have you been under the care of a physician, dermatologist or other medical professional within the past year?*
No
Yes

Yes, explain:

Name of Physician: *

Physician Phone:

2) List all medications you take regularly: *

3) List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:
4) Have you used an acne medication?*
No
Yes

Yes, when?

Which drug?
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:
6) Any skin cancer (past or present)?*
No
Yes

Yes, explain: *
7) Any recent surgery, including plastic surgery?*
No
Yes

Yes, explain:
8) Have you received Botox, Restylane or Collagen injections?*
No
Yes

If Yes, what and when: *
9) Do you have any metal implants or wear a pacemaker?*
No
Yes
10) Do you wear contact lenses?*
No
Yes
11) Do you suffer from sinus problems?*
No
Yes
12) Have you had any piercings, tattoos, or permanent cosmetics?*
No
Yes

If yes, where on your person?
13) Do you form thick or raised scars from cuts or burns?*
No
Yes
14) Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
No
Yes
15) Do you follow a restricted diet?*
No
Yes

Yes, specify:

List your daily consumption of Water: *

List your daily consumption of Caffeine: *

List your daily consumption of Alcohol: *
16) Do you smoke?*
No
Yes
17) Do you follow a regular exercise program?*
No
Yes

If Yes, How many days/Hours do you exercise? *

18) How many hours do you typically sleep each night? *
19) Do you experience any problems sleeping?*
No
Yes
20) What is your stress level?*
21) Have you ever experienced claustrophobia?*
No
Yes
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:
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:

Female Clients Only

24) Are you taking oral contraceptives?*
No
Yes

Yes, specify:
25) Any recent changes to or from your contraceptive treatment?*
No
Yes

If so, what and when?
26) Are you pregnant or trying to become pregnant?*
No
Yes
27) Are you lactating?*
No
Yes
28) Any menopause problems?*
No
Yes

Yes, specify:

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

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. 


Eighth Client's Name

First Name*

Middle Name

Last Name*
Eighth Client's Date of Birth*
Eighth Client's digital form for treatment

Client Information for Treatment 

Single:*
No
Yes
Married:*
No
Yes

Employer:

Occupation: *
1) Does your job require that you work outdoors?*
No
Yes
2) Have you ever had a facial treatment before?*
No
Yes

If Yes, when? *

3) What would you like to achieve from your treatment today? *
4) Which of the following best describes your skin type?*
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:
6) If any, what areas of concern do you have regarding your Eyes?
dark circles
dehydrated
puffiness
wrinkles
Other

If Other:
7) If any, what areas of concern do you have regarding your Lips?
dehydrated
cracked/chapped lips
Other

If Other:

Skincare Information

8) What skincare products are you currently using on your face? *
Day Moisturizer
Eye Cream
Facial Cleanser
Facial Scrub
Mask
Night Cream
Serum
Shower Gel
Soap
Sun Screen
Toner/Astringent
9) Are you currently using a prescribed/recommended professional skincare system from a Dermatologist or Skin Care Professional?*
No
Yes

If Yes, What professional brand are you currently using? *
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
11) Have you used any of these Vitamin A derivative products in the last 3 months?*
No
Yes

If Yes, Please specify:

12) What SPF do you use on your face?

How often/when?

13) What SPF do you use on your body?

How often/when?
14) How frequently are you exposed to the sun or use a tanning bed?*
15) Have you been exposed to the sun or used a tanning bed in the last 48 hours?*
No
Yes
16) Have you had any recent tanning bed or sun exposure that changed the color of your skin?*
No
Yes
17) Have you recently used any self-tanning lotions, creams or treatments?*
No
Yes
18) Have you ever had chemical peels, laser or microdermabrasion?*
No
Yes
Within the last month?*
No
Yes
19) Have you used any of the following hair removal methods in the past six weeks?*
No
Yes

If Yes, How often? *
Yes, check all that apply.
Shaving
Waxing
Electrolysis
Tweezing
Stringing
Depilatories

Male Clients Only: 

20) What is your current shaving system?
Wet Shave
Electric
21) Do you experience irritation from shaving?*
No
Yes