Skincare Treatment Form Page 2
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3Skincare Treatment Form - Continued
7) Have you used any of these products in the last 3 months? m No m Yes
8) Have you used an acne medication? m No m Yes, when? ___________ Which drug? ____________________
Soap _______________________________________
Shower Gels _________________________________
Toner _______________________________________
Body Lotions ________________________________
Mask _______________________________________
Sunscreen ___________________________________
Eye Product _________________________________
SPF _________________________________________
Cleanser _____________________________________
Night Moisturizer/Cream ________________________
Day Moisturizer _______________________________
Other ________________________________________
Exfoliator ____________________________________
Makeup Products _____________________________
Scrubs ______________________________________
_____________________________________________
9) What skin care products are you currently using? (List brand where known)
10) Have you recently used any self-tanning lotions, creams or treatments? m No m Yes, specify:____________ _
11) Have you used any of the following hair removal methods in the past six weeks? m No m Yes, circle all that apply.
Shaving
Waxing
Electrolysis
Plucking
Tweezing
Stringing
Depilatories
12) What areas of concern do you have regarding your: Skin: (Please check any that apply and explain)
Breakouts/acne
Uneven skin tone
o
o
Blackheads/whiteheads
Sun damage
o
o
Excessive oil/shine
Wrinkles/fine lines
o
o
Rosacea
Dull/dry skin
o
o
Broken capillaries
Flaky skin
o
o
Redness/ruddiness
Dehydrated
o
o
Sun spot/liver spot/brown spot
Other ________________________________________
o
Eyes:
dehydrated o wrinkles o puffiness o dark circles o Other: ______________
Lips:
dehydrated o cracked/chapped lips o Other: ______________
13) Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain)
If yes, please explain: ____________________________________________________
Cosmetics
AHAs
o
o
Medicine
Fragrance
o
o
Food
Shellfish
o
o
Animals
Latex
o
o
Sunscreens
Drugs
o
o
Iodine
o
Other ________________________________________
Pollen
o
Continued a
member
Associated Skin Care Professionals
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