Facial Bookings - Skincare Republic

NEW CLIENT INTAKE FORM

Skin Health Questionnaire

Please complete the following, as directed, as thoroughly and in as much detail as possible.

Date

Name

Birthday

Phone Number

Email

Occupation

How did you hear about Skincare Republic?

Please indicate which of the following you are interested in. (Check all that apply.)

What are your goals for your skin?

Medical History

Are you currently or have you previously experienced any of the following (Check all that apply)
Heart Condition Pacemaker Anemia High Blood Pressure Thyroid Condition Hemophilia Diabetes Hepatitis AIDS/HIV Epilepsy/Seizure Disorders Headaches Low Blood Pressure Cancer Kidney Problems Asthma Hypo/Hyperglycemia Herpes Simplex Autoimmune Disorder Keloid Scarring

If you are currently experiencing or being treated for any health or skin-related condition/disorder, please describe:

Please indicate if you have ever used any of the following medications for skin treatment (check all that apply):
Accutane (Isotretinoin) Benzoyl Peroxide Adapalene Differin Tazorac Aczone Cortisone Rx Retin-A Epiduo Clindamycin Salicylic Acid None of the Above

What condition were you treating with this medication, and when was the last time it was used?

Have you had a surgical or non-surgical procedure within the past 5 years? If yes, where on the body was the surgery performed?

Do you have any allergies? Also, list any skin treatment products you have used that caused an unexpected reaction or side effect:

Please list all over-the-counter medications, supplements, and/or prescription medications you are currently taking:

Women
Female clients, please fill out the following:

Are you currently on any type of birth control or hormone therapy?
Yes No

Are you pregnant or trying to become pregnant?
Yes No

Are you currently breastfeeding?
Yes No

Are you going through menopause?
Yes No

If yes, please describe:

Skin Self-Analysis

Is your skin (Check all that apply):
Oily Acne Prone Dry Sensitive Normal

What is your ancestry, if known (ex. Latinx, Irish, Indian, Asian, etc.):

What skincare products are you currently using? Please list what type of product (cleanser/moisturizer, etc.), the brand, and how you use them AM/PM:

Are you currently wearing daily sunscreen?
Yes No

Lifestyle and Stress Analysis

Do you use tanning beds?
Yes No

Do you smoke or vape tobacco?
Yes No

What is your stress level? (1-10)

How much water do you drink daily?

What is your average hours of sleep per night?

Please indicate any of the following that apply to your eating habits:
Fast Food Seafood Dairy Products Pre Workout Supplements

Client Consent

I consent to "before and after" photos for the purpose of documentation, potential advertising, and promotional purpose:
Yes No

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 irritation to the skin from treatments received. I am aware that it is my responsibility to inform the esthetician/skin care therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.

Full Name

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Medical History

Women

Skin Self-Analysis

Lifestyle and Stress Analysis

Client Consent