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Female Clients

Are you on Hormone Replacement Therapy?*

Are you currently on birth control pills?*

Are you pregnant or planning to be?*

About Your Skin

What is one wish you have for your skin?*

What conditions do you want to improve?*(please check all that apply)

What's that?

Do you use any of the following?*(please check all that apply)

What's that?

Do you use a sunscreen/sunblock daily?*

Do you sunbathe or participate in outdoor activities?*

Do you or have you ever had acne?*

Are you using/have used acne medications?*

Name of medication

Do you have any of the following conditions?*(please check all that apply)

What's the "Other" condition?

Are you presently under a doctor’s care?*

What medications do you take on a regular basis?

Have you had any other following?*(please check all that apply)

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Do you smoke?*

Do you take nutritional supplements?*

Do you exercise?

Have you had skin treatments before?*

Are you currently having facials?*

Please list the skin care products you currently use

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Please describe any reactions you have had to any products:

Would you describe your skin as being*

If you experience oiliness throughout the day, about how long does it take after cleansing to feel oily?

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About Your Skin

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