Facial Treatment Client Intake Form

Build a complete skin profile before every appointment: health history, lifestyle habits, current products and sensitivities, closed with a signed confirmation of accuracy. Ideal for estheticians who personalize each facial.

Use this template

Name

Nombre

Apellido

Date of Birth

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Phone Number

Within the last year, have you been under a dermatologist's or other physician's care?

Yes No Not sure

If yes, please specify:

Have you had any health problems in the past or present?

Yes No Not sure

If yes, please specify:

Do you have any allergies?

Yes No Not sure

If yes, please specify:

List any medications, supplements, vitamins, diuretics, slimming pills, Accutane, etc that you take regularly?

Do you smoke?

Yes No Occasionally

Do you exercise regularly?

Yes No Occasionally

Do you follow a restricted diet?

Yes No Not sure

Do you have metal implants, a pacemaker or body piercings?

Yes No Not sure

Do you wear contact lenses?

Yes No Not sure

Do you sunbathe or use tanning beds?

Yes No Occasionally

Do you drink more than 4 caffeinated beverages daily (coffee, tea, soft drinks)?

Yes No Not sure

Have you ever experienced claustrophobia?

Yes No Not sure

What are your specific concerns / challenges with your skin?

What skin care products are you currently using on your face? Please check all that apply.

What skin care products are you currently using on your body? Please check all that apply.

Have you ever had chemical peels, microdermabrasions, or any resurfacing treatments?

Yes No Not sure

If yes, in the last month?

Do you use Retin-A, Renova, Adapalene or any other prescription skin products?

Yes No Not sure

If yes, in the last month?

Are you currently using any products that contain the following ingredients?

Have you ever experienced the following conditions on your skin?

What SPF sunscreen do you use on your face?

What SPF sunscreen do you use on your body?

Do you burn easily in moderate sunlight?

Yes No Not sure

Do you suffer from sinus problems?

Yes No Not sure

Do you ever experience burning, itching or stinging sensations on your skin?

Yes No Occasionally

Do you have a tendency to redness?

Yes No Not sure

Are you taking oral contraception?

Yes No Prefer not to say

Are you pregnant?

Yes No Prefer not to say

Are you lactating?

Yes No Prefer not to say

Are you currently having or due for a menstrual cycle?

Yes No Prefer not to say

Do you have shaving challenges?

Yes No Not sure

If yes, please specify:

Have you started any new medications since your last visit?

Yes No Not sure

If yes, please specify:

*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.

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