scf2 - Academy For Salon Professionals LA

SKIN CONSULTATION FORM

Date *

Name *

First

Last

Street Address

City

State

Zip

Email *

Phone

Age

Ethnicity

Gender

What pressure massage do you prefer?

Light
Medium
Hard

SKIN CONDITIONS

What are your top skin care concerns at this time?

Do you burn easily?

Yes
No

Do you blush easily?

Yes
No

Do you have a tendency towards redness?

Yes
No

Lips:

Dehydrated
Cracked/Chapped lips
Wrinkles
Other

SKINCARE

What skin care products are you currently using?

Cleanser:

Toner:

Moisturizer:

Exfoliant:

Serums:

SPF:

How often do you cleanse your face?

Does your skin have a shine to it by the end of the day?

Yes
No

Could you go without a moisturizer after cleansing?

Yes
No

Do you suffer from sinus problems?

Yes
No

MEDICAL & HEALTH HISTORY

Have you ever used Accutane?

Yes
No

3. Have you undergone surgery in the last year?

Yes
No

How much water do you drink daily?

Do you smoke?

Yes
No

Do you follow a restricted diet?

Yes
No

6. Rate your level of stress on a scale of 1 – 4:

1 - low
2 - mild
3 - elevated
4 - high

Are you experiencing menopause?

Yes
No

Pregnant?

Yes
No

Breastfeeding?

Yes
No

List any medications you are taking:

List any allergies (including aspirin/iodine, etc):

Do you have any metal implants or wear a pacemaker?

Yes
No

Have you ever had an adverse reaction after using any skin care or cosmetic product?

Yes
No

Do you currently have eyelash extensions?

Yes
No

Have you had botox or filler in the past 7 days?

Yes
No

Would you like to receive information about specials/promotions?

Yes
No

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the esthetician/skin care therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.

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