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YOUR CART
Facial Intake
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Indicates required field
Name
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First
Last
Ethnic Skin Type
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Caucasian
African American
Hispanic
Asian
Eastern Indian
American Indian
Pacific Islander
Other
Have you been diagnosed with any medical conditions?
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What is your general state of health?
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Are you pregnant?
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Yes
No
Do you have any known allergies?
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Please list all medications you are taking:
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Are you currently or in the past 2 weeks been prescribed Anti-biotics?
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Yes
No
If yes, what? is it oral or topical? and how long have you been on it?
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Have you had any medical procedures in the last two months, to any area we will be treating? Including cosmetic procedures (peels, fillers, botulism, etc)
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Are you currently using, or in the past 6 months used:
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Tretinoin, Retin-A, Renova, or Refissa
Differn
Any products with Glycolic, Salicylic or Lactic acid
Accutane
None
What are your skin concerns and/or goals, for today and long-term?
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On a scale from 1-10, what is your level of stress? Does it vary much?
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How would you describe your eating habits? Do you have issues with digestion or any discomforts when you eat?
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Do you drink alcohol? If so, how much and how often?
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Do you smoke?
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Yes
No
Sometimes
How many 8oz glasses of water do you drink per day?
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0-2
3-6
7-10
more than 10
How often do you exercise?
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Everyday
Once per week
2 to 3 times per week
Once per month
Less than once per month
What type of exercise do you do?
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On average, how many hours of sleep do you get?
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How many hours are you outside per day? Does it vary greatly? At what times mostly?
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How many hours are you in your car per day? At what times?
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Do you use a tanning both?
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Yes
No
If yes, how often?
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N/A
A few times per week
Once per week
A few times per month
Once per month
Less than once per month
Have you had a facial before? How frequently? Did you have any specific likes or dislikes?
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What skin care products do you use?
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Skin Cleanser
Toner
Exfoliant
Serum
Moisturizer
Eye cream
Neck cream
Sun Protector
Please select all that apply.
Where do you buy your skin care products?
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Drug Store / Grocery Store
Department Store
Specialty Beauty Store (Sephora, Ulta, etc.)
Esthetician / Spa
Cosmetic Surgeon
Other
Please select all that apply.
Brands and product names:
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It is very helpful to know exactly what you are using, so please be specific when possible. You may also bring them with you to your appointment.
Are you happy with your current products? Are you happy with the results?
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How many times per day do you do your routine?
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Do you use a stand alone sun protector or is it in a moisturizer or makeup? How frequently do you apply it?
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Any other information you feel is pertinant
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Submit