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Permanent Makeup Pre-Procedure Questionnaire

Screen clients for permanent makeup before their appointment. It asks about past procedures, pregnancy, recent surgery, medications and health conditions, plus preferences for brows, lips and eyeliner.

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Date

Name

First Name

Last Name

Phone number

Have you had permanent makeup before?

Yes No

If so, tell us about the procedure

May we contact your previous practitioner?

Yes No Not applicable

Previous practitioner's name

First Name

Last Name

Previous practitioner's phone

Are you pregnant or breastfeeding?

Yes No

Have you had facial surgery recently?

Yes No

Have you had an organ transplant?

Yes No

Are you planning a vacation in the next 3 weeks?

Yes No

Which medications do you take?

Blood thinners or aspirin Retinoids (e.g. isotretinoin) Antibiotics Steroids Immunosuppressants None

Do you have any of the following conditions?

Diabetes Heart condition Bleeding disorder Keloid scarring Autoimmune disease Skin condition (eczema, psoriasis) None

How much hair do you have in your brows?

Full Medium Sparse Almost none

Lip liner only, or liner with shading?

Liner only Liner with shading Full lip color Not sure yet

How thick would you like your eyeliner?

Thin Medium Thick Winged

Consent notice

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