Your Health

1. Within the last year, have you been under a dermatologist or other physician’s care? Yes No
2. Within the last nine months have you undergone any surgery? Yes No      If yes, please specify
3. Have you had any health problems in the past or in the present? Yes No      If yes, please specify
4. List any medications, supplements, vitamins, diuretics, slimming tablets etc. that you take regularly.          
5. Do you smoke? Yes No
6. Do you exercise regularly? Yes No
7. Do you follow a restricted diet? Yes No
8. Do you wear contact lenses? Yes No
9. Do you have mental implants, a pacemaker or body piercings? Yes No
10. Rate yourself of stress on a scale of 1 to 4 (1=low stress, 4 = high stress).                 1 2 3 4

Your Skin

1. Do you have any special skin problems pertaining to your face or body?               Yes No If yes, please specify
2. What skin care products are you currently using? Face Soap Cleanser Toner Moisturiser Masque Exfoliator Eye products                 Body Soap Shower gel Scrubs Oil Body moisturiser Depiliatory products Self tanners   
3. Have you ever had chemical peels, micrdermabrasion, or any resurfacing treatments? Yes No In the last month? Yes No
   
4. Do you use Accutane, Retin A, Renova, Adapalene or any other prescription skin products? Yes No In the last 3 months? Yes No
5. Are you currently using any products that contain the following ingredients?              Glycolic acid Lactic acid Any exfoliating scrubs Any hydroxyl acid product Vitamin A derivatives (i.e. retinol)

Moisture Hydration

1. How much plain water do you consume daily?
2. How many alcoholic beverages do you consume weekly?
3. Do you ever experience these conditions on you skin? Flakiness Tightness Obvious dryness
4. What spf sunscreen do you use on your face?            Body
5. Do you sunbathe or use tanning beds? Yes No

Capillary Activity

1. Do you burn easily in moderate sunlight? Yes No
2. Do you blush easily when nervous? Yes No
3. Do you have a tendency to redness? Yes No
4. Do you suffer from sinus problems? Yes No

Oil Selection

1. Do you ever experience oily shine during the day? Yes No Occasionally
2. Do you ever experience skin breakouts? Yes No Occasionally

Nerve Activity

1. Do you drink more than 4 caffeinated beverages daily (coffee, tea,
             soft drinks)?

   Yes No
2. Do you ever experience a burning, itching sensation on you skin? Yes No
3. What is your pain threshold? Low Medium High
4. Have you ever experienced claustrophobia? Yes No
5. What type of massage pressure do you prefer? Light Medium Firm
6. Have you ever had a reaction to any of the following? Cosmetics Medicine Iodine Pollen Food Hydroxyl acids Animals Fragrance Sunscreens      Other

Female Clients Only

1. Are you taking oral contraception? Yes No
2. Are you pregnant or trying to become pregnant? Yes No
3. Are you lactating? Yes No

Male Clients Only

1. What is your current shaving system?

   Yes No

2. Do you experience irritation from shaving?

   Yes No
3. Do you experience ingrown hairs? Yes No

Questions to Discuss at Every Visit

1. Are you currently having or due for your menstrual period?

   Yes No
2. Have you started any new medication since your last visit? Yes No
3. Have you ever had any recent dental x-rays? Yes No
4. What are your skin care goals?