Skin Health Form

1. Please check if you have had any of the following in the past 6 months: *
2. Please check if you have been treated for any of the following: *
3. Are you prone to cold sores? *
4. If yes when was your last active breakout?
5. Are you pregnant, trying to get pregnant, or undergoing hormone therapy? *
6. Do you smoke, or live with a smoker? *
7. Do you have a pacemaker or any other electrical implant? *
8. List any vitamins, supplements, or prescription drugs you are currently taking as well as any allergies: *
9. Rate your current stress level *
1 2 3 4 5 6 7 8 9 10
10. How many ounces of water do you drink daily? *
11. Do you exercise? *
12. If yes, how often?
13. Do you use a tanning bed? *
14. When was your last sunburn? *
15. Have you ever been under the treatment of a Dermatologist, Plastic Surgeon, or Esthetician? *
16. If yes, for what procedure(s)?
17. What skin care line are you currently using?
18. Do you use a daily SPF? *
19. If no, why not?
20. Which of the following BEST describes your skin type? *
21. Which of the following skin conditions are you concerned about? *
22. Rate the overall quality of your skin? *
1 2 3 4 5 6 7 8 9 10
Sign Below *