Name
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First Name
Last Name
Email
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Phone
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(###)
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Date of birth
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Where did you spend the first 20 years of your life? (ie: born in Florida, grew up by the beach and in the sun for most of my first 20 years)
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What do you like about your skin?
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What do you dislike about your skin?
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List 3 skin health goals
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Medical history
Please check all that apply.
Are you currently seeing another skin therapist and/or dermatologist?
Are you under the care of any health care professionals or specialists? (ie: nutritionist, naturopath, cardiologist)
Have you had any previous skin treatments such as chemical peels, microdermabrasian, resurfacing treatments, or any other ablative treatments?
What is your skin type and/or condition?
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Do you have any other problematic areas? (ie: bikini line, back, chest)
Current morning skincare routine (please list in order with product name)
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Current evening skincare routine (please list in order with product name)
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Current makeup products you use (ie: foundations, blush, etc)
What shampoo and conditioner do you use?
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What is the health of your scalp?
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How often do you shampoo your hair per week?
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When do you wash your conditioner out?
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Do you experience dry, flaky skin behind or in your ears?
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How do you like your shower temperature? (ie: very warm)
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Do you wash your face in the shower?
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What toothpaste do you use?
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Do you floss your teeth at night?
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Are you cavity prone?
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What is your occupation?
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How many hours a week do you work?
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Does your job require you to work outdoors?
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Does your job require long distance driving?
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Do you work around chemicals, tars, oils, grease, or inks?
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On a scale from 1-10, how stressful is work?
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Do you work night shifts?
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Do you wear a mask at work?
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Have you ever or are you currently taking Accutane, Retin A, Spironolactone, or any other acne medications?
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Are you currently on or have you taken antibiotics in the past 6 months?
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Are you currently pregnant?
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Are you currently trying to get pregnant?
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Are you currently nursing?
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Have you taken birth control in the past 12 months via pills, shots or IUD? If yes, please list the name of your birth control prescription and how long you were taking it.
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Are your menstrual cycles regular?
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Are you peri-menopausal, menopausal, post-menopausal or none of the above?
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Do you have any health conditions that could be effecting your skin health? (ie: PCOS, autoimmune)
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Do you tan easily after sun exposure?
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Do you wear sunscreen daily?
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Do you reapply your sunscreen every 2-3 hours?
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Do you tan in a tanning bed?
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Have you had any recent UV exposure that changed the color of your skin? Please explain.
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Do you have any environmental allergies? (ie: pollen, dust, mold, pet, grass)
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Do you have any product allergies? (ie: fragrance, citrus, latex, mango, pumpkin)
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Do you have any food allergies? (ie: shellfish, nuts, citrus, wheat)
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Do you have or have you ever had asthma, eczema, psoriasis or dermatitis?
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Is your skin sensitive and/or reactive? If yes, what makes it sensitized/reactive?
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Does your skin mark, tear, or bruise easily?
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How many cups of water do you drink, daily?
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What type of water do you drink? (ie: tap, filtered, bottled)
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How many caffeinated beverages (coffee, tea, soda, etc.) do you consume daily?
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Do you drink coffee on an empty stomach?
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What did you eat yesterday? (breakfast, lunch, dinner, snacks, drinks, dessert if applicable)
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Do you consume the following?
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Do you eat breakfast?
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How often do you poop?
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Do you have any digestion or elimination concerns?
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What supplements, vitamins, minerals are you currently taking? (ie: digestive enzymes, vitamin c, zinc)
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How many times per week do you dine out/get take out?
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How many servings of vegetables do you have per day?
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How many servings of fruits do you have per day?
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Do you cook with/eat herbs & spices? (ie: basil, sage, ginger, parsley, turmeric)
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Do you drink hot tea/tea? (ie: peppermint, green tea)
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How many hours do you leave between your last meal and bed time?
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How many cups of liquid do you drink whilst eating?
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How many alcoholic beverages do you treat yourself to per week?
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Do you smoke cigarettes/vape?
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Do you take any recreational drugs? (ie: marijuana)
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How many days a week do you move your body? (ie: at least 15-20 minutes of movement, walking, biking, lifting)
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Do you partake in any competitive sports?
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How often do you swim in a chlorinated pool?
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Do you spend a lot of time in the sun?
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Do you garden?
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Please describe which statement resonates with you best:
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What triggers your stress levels?
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Do you take NSAIDS? Think headaches, etc. (ie: ibuprofen, Advil, aspirin)
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What time do you generally wind down for the evening?
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Do you have trouble falling asleep at night?
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Do you take any medication or herbal remedies to help you sleep? If so, what do you take?
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How much screen time do you consume daily?
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On average, how many hours of quality sleep do you get per night?
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Do you have sleep apnea?
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How often do you wash/change your pillowcases and sheets?
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How often do you wash your makeup brushes?
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Have you been exposed to mold?
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What detergent do you use to wash your clothes?
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Do you use fabric softener or fabric softener sheets in the dryer?
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Do you wear perfume? If yes, what perfume(s)?
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What deodorant do you wear?
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What support would you like from us? (ie: facials, skin consult, help with skin routine)
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What is your preferred form of contact? (ie: text, call, email, fb message)
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How did you hear about us?
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