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Facial Intake Form
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Name:
Your answer
Date of Appointment:
MM
/
DD
/
YYYY
Address:
Your answer
Phone Number:
Your answer
Preferred Email:
Your answer
Skin Type
Dry
Sensitive
Acne
Oily
Complexion
Occasionally dull; sometimes burns
Shallow; burns easily
Red undertones; always burns
Shiny; rarely burns
Occasionally shiny; burns after a while
Texture
Some dryness, thin skin, small pores
dry, thin skin, invisible pores, fine lines
Delicate, soft, smooth, inflammation
soft skin, some puffiness, large pores
smooth, thick skin, medium pores
Challenges
Spot dryness, lack of moisture
Flaky, rough
Prone to irritation, rash/itch/breakouts
Excess oil, blackheads, whiteheads, acne
Oily T-zone, spot blemish
Energy Level
High
Sporadic
Consistent
Slow but consistent
Low
Stress Response
Nervousness
Anxious/worry
Angry/irritable
Emotional
Withdrawal
Clear selection
Have you ever had a facial
Yes
No
Clear selection
Are you currently under stress
Yes
No
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What types of beverages do you consume daily?
Your answer
Past or present health conditions:
Hypoglycemia
Alcoholism
Cancer
Heart Problems
Smoking
Pregnancy
Hysterectomy
Hepatitis
Claustrophobia
Diabetes
Asthma
Epilepsy
High Blood Pressure
Low Blood Pressure
Thyroid Disorder
Hormonal Disorder
Rosacia
Lash Extensions
Sensitivity to Steam
Have you recently used any of the following products:
Retin-A
Accutane
Antibiotics
Diuretics
Oral Contraceptives
Have you undergone treatment from a dermatologist?
Yes
No
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Have you ever experienced an allergic reaction to skin care products? If yes, which one?
Your answer
What products are you currently using
Your answer
What are your specific concerns with your skin?
Your answer
Do you have any metal plates, pins, or pacemaker?
Yes
No
Clear selection
Are you allergic to shellfish or aspirin?
Yes
No
Clear selection
Do you typically wear contact lenses
Yes
No
Clear selection
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