Confidential Client Health History & Consultation Form Page 3
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Client Consultation
1. What skin care products are you currently using? (list brand where known)
Soap _______________________________ Shower Gels _____________________
Toner ______________________________ Body Lotions _____________________
Mask ______________________________ Sunscreen _______________________
Eye Product _________________________ SPF ____________________________
Cleanser ____________________________ Night Moisturizer _________________
Day Moisturizer _______________________ Other __________________________
Exfoliator ____________________________ Makeup Products _________________
Scrubs _______________________________ Self Tanner _____________________
2. Have you recently used any of the following hair removal methods in the past six
weeks? __No __Yes Circle all that apply.
Shaving
Waxing
Electrolysis
Plucking
Tweezing
Stringing
Depilatories
3. What areas of concern do you have regarding your :
Skin: (Please check any that apply and number according to importance to you)
_____Breakouts/acne
_____Uneven skin tone
_____Blackheads/whiteheads
_____Sun Damage
_____Excessive oil/shine
_____Wrinkles/fine lines
_____Rosacea
_____Dull/dry skin
_____Broken capillaries
_____Flaky skin
_____Redness/ruddiness
_____Dehydrated
_____Sun spot/liver spot/brown spot
_____Other__________________________
Eyes:
_____Dehydrated
_____Wrinkles
_____Puffiness
_____Dark circles
__other
Lips:
_____Dehydrated
_____Cracked/chapped lips
_____other
4. Which of the following best describes your skin type? (Please Circle one)
I
Creamy complexion – Always burns easily, never tans
II Light Complexion- Always burns, tans slightly
III Light/Matte Complexion-Burns moderately, tans gradually
IV Brown Complexion- Rarely burns, deep tan
VI Black Complexion-Never burns, deeply pigmented
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. The treatments I
receive here are voluntary and I release this institution and/or skin care professional from
liability and assume full responsibility thereof.
Client Signature: ___________________________________________Date:______________
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