Skin Questionnaire We can’t wait to have you in the studio! please fill out this questionnaire at least 48 hours before your skin consultation. CONTACT INFO Name * First Name Last Name Email * Phone * CLIENT HEALTH and DIET Age * Are you in Good Health? * Yes No Please List Any Medications You Are Currently Taking * Please List Any Allergies * Please List Any Vitamins, Herbs, Or Supplements You Take Regularly * Does Your Diet Include Any Of The Following? * Dairy Peanuts Wheat Fruit Soy Sugar No, my diet does not include any of the above. Daily Intake Of Water (Cups) * Daily Intake Of Coffee (Cups) * Daily Intake Of Tea (Cups) * Daily Intake Of Soda (Cans) * How Often Do You Drink Alcohol? * Do You Use Tobacco Products? * Yes No Are You Pregnant, Trying to Become Pregnant, Or Lactating? * Yes No SKIN HEALTH What Best Describes Your Facial Condition? * Oily Dry Sensative Normal I don't know Which Of The Following Would You Like To Improve? * Acne Enlarged Pores Blackheads Wrinkles/Signs Of Aging Pigmentation Issues Clogged Pores Rosacea Scarring Eczema None of the Above Do You Currently Use Any Of The Following On Your Face? * Chemical Peels Scrubs Laser/IPL Microdermabrasion RetinA (Prescription Vit A, Tretinoin) Glycolic Acid Benzoyl Peroxide Salicylic Acid None of the Above Please List Products And Brands Of Skincare Are You Currently Using Do You Sunburn Easily? * Yes No Do You Tan Easily? * Yes No Do You Use A Tanning Bed? * Yes No Do You Have Any Active Facial Skin Cancer? * Yes No Details And/Or Adverse Reactions If Applicable To The Above Question What Are Your Long Term Skin Care Goals? * Is There Anything Else I Should Know? Face Sculpting If you have scheduled a Face Sculpting Service or are interested in adding Face Sculpting to your service, please complete the below. If not, you may skip this section. Please check all that apply to you: I've had a recent surgery to my face or neck. My Face Sculpting/Skin Service is less than 2 weeks from my last botox appointment. My Face Sculpting/Skin Service is less than 3 months from my last filler appointment. I have PDO threads. I've had recent dental work. I currently use topical steroids/antibiotics. None of the Above Please select any areas you wish to improve: Receding hair line Forehead lines Heavy eyelids Undereye wrinkles/crows feet Volume loss in cheeks Marionette lines Crinkled chin Double chin Horizontal neck lines Vertical chest lines None of the above Model Consent (Optional) From time to time, Rejuvenate Skincare & Wellness needs models for training, service demonstrations, promotional material, or content creation purposes. Models are compensated with free or discounted services, depending on the service provided. By checking this box, you hereby give your consent to be a model for Rejuvenate Skincare & Wellness at a future date and authorize us to reach out to you when models are needed. Yes, I consent. Thank you!
