Client Profile Card Form (Page 2 of 2) in pdf

Client Profile Card Form Page 2

FEMALE CLIENTS ONLY: Are you trying to become pregnant? Yes ____ No _____

Do you ever experience skin break-outs? Regularly ( ) Occasionally ( ) Never ( )

What type skin do you believe you have? Normal ( ) Dry ( ) Oily ( ) Combination ( )

Do you have redness in your cheeks? Yes ______ No ___Sunburn easy? Yes ____ No ______

Do you have comedones (blackheads)? Yes _____ No _____Milia (whiteheads)? Yes____ No ____

Brand of Personal skin care products: Soap ____________ Cleanser ________________________

Toner __________________Scrub __________________ Masque ____________________________

Moisturizer _____________________Sunscreen SPF # _____________________________________

Other_______________________________________________________________________________

I am responsible for any valuable items I bring into the treatment room with me.

Client Signature _____________________________________________Date ____________________

Client Profile Card Form Page 2