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 ____________________