Greatskinohio.com

Skin Care History Questionaire and WaiverPlease answer the following questions so that your Skin Care Specialist may have a better understanding of your general health and lifestyle, thereby enabling your Skin Care Specialist to accurately analyze and assess your skin care needs.
Name: ___________________________________________________________Date: _________________________ Address: _________________________________________________________________________________________ City: _________________________________________________State: ________________ Zip: _________________ Home Phone: __________________________________ Business Phone: _________________________________ Cell Phone: ________________________________________ Date of Birth: ________________________________ E-mail address: ___________________________________________________________________________________ What type of work do you do? ___________________________________________________________________Have you seen a dermatologist in the past year? Yes________No________If yes, list dermatologist’s name, contact info and reason for visit____________________________________ __________________________________________________________________________________________________ Are you presently under a physician’s care? Yes________No________If yes, list physician’s name and reason for visit _____________________________________________________ __________________________________________________________________________________________________ Are you currently taking any medications? Yes________No________ If yes, please list __________________ __________________________________________________________________________________________________ What is your genetic background? ________________________________________________________________ How is your general health? ______ Excellent ______ Good ______ Fair Please rate your stress level from 1-5 (5 being the highest): __________ Please circle the following conditions you have or had experienced: •hypertension
•contact lenses
•high cholesterol
•asthma
•metal plate
•anemia
•varicose veins
•hepatitis
•diabetes
•lupus
•seizures
•tooth fillings
•fainting
•irregular pulse
•eating disorder
•high/low blood
•cold sores
•claustrophobia
•heart attack
•hernia
•cancer
•epilepsy
•autoimmune disorder
•stroke
•thyroid disorders
•headaches
Allergies:
Have you ever had an allergic reaction to any of the following:ASPIRIN OR SALICYLATES If checked yes to any of the above, please explain ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Please list any other known allergies: __________________________________________________________________________________________________Have you ever had Herpes Simplex? If yes, have you ever been treated with Denavir® (Penciclovir), Zovirax® (Acyclivor) or Abreva?Yes_______ No________Are you being treated for Hepatitis? Female clients only:
Are you presently taking birth control pills? Skin Care HistoryAre you currently having skin treatments? Yes________ No________If yes, what type of treatment(s)___________________________________________________________________Please check if you are presently using or have used in the past any of the following:________ Benzoyl Peroxide (BP)________ Glycolic Acid (AHA)________ Lactic Acid (AHA)________ Resorcinol________ Salicylic Acid (BHA) Do you have or have you had any of the following in the last 14 days?________ Facial Cosmetic Surgery________ Botox Injections ________ Collagen Injections________ Fillers________ Light Treatments________ Laser Resurfacing ________ MicrodermabrasionOther ____________________________________________________________________________________________ HOME CARE:What Skin care products are you currently using at home?Cleanser _________________________________ Vitamin C ______________________________________ Toner ____________________________________ Exfoliants/Scrubs ________________________________ Moisturizer ________________________________ Specialty Products ______________________________ SPF _______________________________________ Mask ___________________________________________ PRESCRIPTION PRODUCTS:________ Tretinoin (Retin A, Retin-A Micro®, Renova, Avita) ________ Azelaic Acid (Azelex®, Finacea™) Any other topical antibiotics_______________________________________________________________________ PLEASE CHECK IF YOU ARE PRESENTLY EXPERIENCING OR HAVE EXPERIENCED ANY OF THE FOLLOWING:________ Skin Cancer Do you sunbathe or participate in outdoor activities? Have you tanned in a tanning booth in the last 14 days? Have you had any direct sun exposure in the last 10 days? WHEN EXPOSED TO THE SUN DO YOU:________ Always burn, never tan ________ Always tanDo you feel your skin is sensitive? WHAT SKIN CONDITIONS DO YOU WANT TO IMPROVE?________ Acne and/or breakouts ________ Hyperpigmentation (freckles, age spots) OTHER ____________________________________________________________________________________________ Is there any other necessary information your Skin Care Specialists should know before beginning your treatment? If yes, please explain _______________________________________________________________________________________________________________________________________________________________________________ I have acknowledged that all the information provided by me is true and correct to the best of my knowledge. I understand that some skin conditions may require more than one treatment and home care products to achieve the result desired. Results cannot be guaranteed due to individual skin type(s) and condition(s). I understand I need to sign this waiver prior to every treatment provided, with ANY changes pertaining to the Client Signature: __________________________________________Date:_______________________________
Client Signature: __________________________________________Date:_______________________________
Client Signature: __________________________________________Date:_______________________________
Client Signature: __________________________________________Date:_______________________________
Client Signature: __________________________________________Date:_______________________________
Client Signature: __________________________________________Date:_______________________________
Client Signature: __________________________________________Date:_______________________________
Please check if permission is granted to use pictures for marketing and training purposes. glō•therapeutics Treatment RecordCLIENT'S NAME: ___________________________________________________________DATE: ____________________________CLIENT'S CURRENT SKIN CARE PRODUCTS: __________________________________________________________________________________________________________________________________________________________________________________TREATMENT PROVIDED________________________________________________________________________________________AREA TREATED: __________________________________ HOW MANY LAYERS / TIME LEFT ON SKIN: _____________________PRODUCT USED TO PREP SKIN: Peel Prep MASK: None Soothing Gel Mask Calming Seaweed Mask Restorative Mask Refining MaskADDITIONAL PRODUCTS USED:__________________________________________________________________________________RESULTS: Redness Hot Spots Frosting OtherCOMMENTS: __________________________________________________________________________________________________ CLIENT'S NAME: ___________________________________________________________DATE: ______________________________CLIENT'S CURRENT SKIN CARE PRODUCTS: ______________________________________________________________________________________________________________________________________________________________________________________TREATMENT PROVIDED__________________________________________________________________________________________AREA TREATED: __________________________________ HOW MANY LAYERS / TIME LEFT ON SKIN: ______________________PRODUCT USED TO PREP SKIN: Peel Prep MASK: None Soothing Gel Mask Calming Seaweed Mask Restorative Mask Refining MaskADDITIONAL PRODUCTS USED:__________________________________________________________________________________RESULTS: Redness Hot Spots Frosting OtherCOMMENTS: __________________________________________________________________________________________________ CLIENT'S NAME: ___________________________________________________________DATE: _______________________________CLIENT'S CURRENT SKIN CARE PRODUCTS: ______________________________________________________________________________________________________________________________________________________________________________________TREATMENT PROVIDED__________________________________________________________________________________________AREA TREATED: __________________________________ HOW MANY LAYERS / TIME LEFT ON SKIN: _______________________PRODUCT USED TO PREP SKIN: Peel Prep MASK: None Soothing Gel Mask Calming Seaweed Mask Restorative Mask Refining MaskADDITIONAL PRODUCTS USED:__________________________________________________________________________________RESULTS: Redness Hot Spots Frosting OtherCOMMENTS: __________________________________________________________________________________________________

Source: http://www.greatskinohio.com/docs/GloFacialHX.pdf