Facial Intake

Ethnic Skin Type *

Caucasian African American Hispanic Asian Eastern Indian American Indian Pacific Islander Other

Have you been diagnosed with any medical conditions? *

Please list all medications you are taking: *

Are you currently or in the past 2 weeks been prescribed Anti-biotics? *

Yes No

If yes, what? is it oral or topical? and how long have you been on it? *

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) *

Are you currently using, or in the past 6 months used: *

What are your skin concerns and/or goals, for today and long-term? *

On a scale from 1-10, what is your level of stress? Does it vary much? *

How would you describe your eating habits? Do you have issues with digestion or any discomforts when you eat? *

Do you drink alcohol? If so, how much and how often? *

How many 8oz glasses of water do you drink per day? *

On average, how many hours of sleep do you get? *

How many hours are you outside per day? Does it vary greatly? At what times mostly? *

How many hours are you in your car per day? At what times? *

Have you had a facial before? How frequently? Did you have any specific likes or dislikes? *

Where do you buy your skin care products? *

Brands and product names: *

Are you happy with your current products? Are you happy with the results? *

How many times per day do you do your routine? *

Do you use a stand alone sun protector or is it in a moisturizer or makeup? How frequently do you apply it? *

Any other information you feel is pertinant *

YOUR CART

Facial Intake
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YOUR CART

Facial Intake. . . . . . . . . . . . . .

Facial Intake
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