(microsoft word - skin\225di\225tion consultation form.docx)

Verb: The transformation from skin condition to skin perfection Skindition Mobile Spa - Client Profile
It is important to answer all questions honestly to ensure you receive treatments for your skin and health. First Name: ______________________________ Last Name: __________________________________ Date: ____________________________________ Address: __________________________________________________________________________________ City:_____________________________________ Province: ____________________________________ Phone Number: ____________________________ Alternate Phone Number: ______________________ E-mail Address: ____________________________ Birthday: ____________________________________ How did you hear about Skindition Mobile Spa? _________________________________________________ What is the reason for your visit today? _________________________________________________________ Health History
1. Within the last year, have you been under the care of a physician or dermatologist? 2. Within the last year, have you undergone any surgery or aesthetic surgeries? If yes, please specify? ____________________________________________________________________ 3. Within the last 5 years, have you undergone any radiotherapy or chemotherapy? If yes, please specify? ____________________________________________________________________ 4. List any medications, supplements, vitamins etc. that you take regularly. __________________________ 5. Have you ever had a cosmetics reaction? 12. Do you have any metal implants, a pacemaker or body piercing? 13. Rate your level of stress on a scale of 1 to 4 (1= low stress, 4= high stress) _________________________ 14. Have you experienced any of the following conditions? Other, please specify _________________________________________________________________________ 15. Do you have any special skin problems pertaining to the face and body? If yes, please specify _________________________________________________________________________ 16. What skin care products are you currently using? ☐soap ☐cleanser ☐toner ☐moisturizer Body: ☐soap ☐shower gel ☐scrubs ☐oil 17. Do you ever experience these conditions on your skin? 22. What SPF do you use on your face? ________________________ 23. Do you ever experience oily shine during the day? 24. Do you have concerns with uneven skin tone? Exfoliation History
26. Have you ever had chemical peels, microdermabrasion or any resurfacing treatments? If yes, please specify _________________________________________________________________________ 27. Do you use Accutane, Retin – A or any other prescription products? 28. Are you currently using any of the following exfoliation products? ☐Salicylic acid ☐Vitamins A derivatives (i.e. retinol) 29. Do you have metal implants/pace maker or body piercings? I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment.

Source: http://www.skindition.ca/SKINDITION%20CONSULTATION%20FORM%20PDF.pdf