CONFIDENTIAL SKIN HEALTH QUESTIONNAIRE Date Cell Name Email Occupation Date of Birth Age Do you smoke How often Living with a smoker HAVE YOU BEEN TREATED FOR: (PLEASE CHECK) ACNE Depression Skin Diesase High Blood Pressure Cold Sores Diabetes Cancer LIST OF ALL ALLERGIES/ ALLERGIC: LIST ALL MEDICATIONS THAT YOU ARE CURRENTLY TAKING: Are you pregnant Trying to get pregnant Honmone therapy ARE YOU PRONE TO COLD SORES? CIRCLE YOUR CURRENT LEVEL OF STRESS: 1 2 3 4 5 6 7 8 9 10 CIRCLE YOUR NORMAL LEVEL OF STRESS: 1 2 3 4 5 6 7 8 9 10 HOW MANY OUNCES OF WATER DO YOU DRINK DAILY? Do you take any supplements/vitamins? Your last sunburn? Do you exercise? If so, how often? Do you use tanning beds? WHEN YOU GO OUT IN THE SUN, DO YOU (PLEASE CHECK): Always burn Usually burn Sometimes burn Rarely burn Very rarely burn Never burn HAVE YOU BEEN UNDER THE TREATMENT PLAN OF A: Dermatologist Plastic surgeon Esthetician Would you be interested In plastic surgery? If yes, what procedure? ARE YOU CONCERNED ABOUT SKIN CONDITIONS ON YOU BODY? (CHECK ALL THAT APPLY) Sun spots Skin laxity Dry/rough patches What skin line are you currently using? Do you use a daily environmental protection product (sunblock)? If not, why? Circle how you feel about overall quality of your skin: (BAD) 1 2 3 4 5 6 7 8 9 10 (FANTASTIC) YOUR SKIN TYPE IS? (PLEASE CHECK ONLY ONE) Normal Dry/dehydrated Oily Acne/acne prone Rosacea IN ORDER OF IMPORTANCE, PLEASE RANK 1 (MOST IMPORTANT) TO 5 (LEAST IMPORTANT): Reduction of fine lines Acne scars diminished Reduction of redness Reduction of brown spots/ sun damage Reduction of oil/acne THANK YOU FOR COMPLETING THIS CONFIDENTIAL QUESTIONNAIRE. THIS INFORMATION WILL ALLOW YOUR PROFESSIONAL SKIN CARE SPECIALIST TO PROVIDE THE OPTIMUM IMAGE PRODUCTS AND SERVICES. SIGNATURE: Date Acknowledge
