Effleurage Studio Intake
Email *
First Name
 *
Last Name
 *
Address *
Telephone *
Email *
Birthdate *
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Date of Consultation *
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Occupation *
Gender *
Required
Are you now or within the last year under a physician's care? Dermatologist? Plastic Surgeon? *
Required
Have you undergone any surgery in the last nine months? *
Required
Have you had any of these health problems past or present? *
Required
List any medications and vitamins that you take regularly?
Do you have permanent make-up? *
Required
Do you have any special skin problems or concerns pertaining to your face? *
Required
Do you have any special concerns pertaining to your body? *
Required
Do you do the following? *
What types of skin care products are you currently using daily? *
Required
Have you ever had a facial treatment before? *
Required
Have you ever had plastic surgery? *
Have you ever had?
FEMMALE CLIENTS ONLY
Are you taking oral contraception? *
Required
Are you now trying to become pregnant?
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MALE CLIENTS ONLY
What is your current shaving system?
Do you experience irritation from shaving? *
Do you experience ingrown hairs? *
Required
Do you wish you could get a closer shave?
OIL SECRETION
Do you experience breakthrough oily shone during the day? *
Required
Do you experience skin breakouts? *
Required
MOISTURE HYDRATION
How many glasses of plain water do you consume daily? *
Required
How many alcoholic beverages do you consume weekly? *
Required
Do you ever experience any of the following conditions on your skin? *
Required
Do you use sunscreen/sunblock? *
Required
CAPILLARY ACTIVITY
Do you burn easily in moderate sunlight? *
Required
Do you blush easily when nervous? *
Required
When/if drinking alcohol, do your cheeks turn red? *
Required
When/if eating salt, do you experience puffy skin (possibly around the eye area)? *
Required
Do you have natural tendency to redness? *
Required
Have you ever suffered any sinus problems? *
Required
Nerve Activity
How many cups of caffeine-type beverages (coffee, tea. soft drinks) do you drink daily? *
Required
What level do you consider your pain threshold to be? *
Required
Have you ever experienced any claustrophobia? *
Required
Have you ever experienced a reaction to any of the following?
Questions to Update Each Visit
Are you currently having or due for your menstrual period? *
Required
Have you started any new medications? *
Required
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