New Client Skin Care Questionnaire

Personal and Confidential

If you are a new client, please fill out the form below so we can create a personalized skin care plan customized for you. Once you submit the form, it usually takes less than 1 business day to get a response.

1. Please provide the following information for the person this Skin Care Plan is for:

malefamale

2. Concerns & Interests





3. Current Health & Lifestyle


Dry (facial skin is very dry)Oily (entire face is very oily)Combination (t-zone tends to be oily)Normal

yesno

Mild (red bumps and pustules that come & go)Moderate (red bumps and pustules that come & go)Severe (presistent nodules & cysts that are resistant to treatment)N/A

yesno

RosaceaPsoriasisNo

yesno



yesno

yesno


yesno


yesno


Never6 Months1 Year2 Year

yesno

Bleeding ProblemsSkin CancerStomach UlcersHigh Blood PressureHivesTuberculosisX-Ray TherapyHeart MurmurCardiac PacemakerEczemaFainting SpellsOther

yesno

yesno

Enlarged poresBlotchy or uneven pigmentSaggy facial skinFine lines around eyes and mouth