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Skincare Intake Form

    First Name
    Last Name
    Date of Birth
    Street
    Apt. #
    City
    State
    Zip
    Phone – Home
    Work
    Mobile
    Dermatologist/physician
    Phone
    Emergency Contact
    Phone

    Email

    Referred by
    FriendMailerWalk-byE-mailGift CertificateOther

    Other

    Skin Care Professional Name:

    What is the reason for your visit today?

    What special areas of concern do you have?

    EXPECTATIONS and HISTORY

    Which conditions would you like to improve?

    Acne scarringAcneAge spotsEnlarged PoresFine lines & wrinklesHyperpigmentationBroken CapillariesStrectch MarksSurgical/Facial scarsOther

    Other

    Have you ever had facial treatment in the past?
    YesNo

    What was your experience?

    How would you describe your skin?
    NormalDryOilyCombinationSensitiveSun Damaged

    How would you rate your skin?

    Do you ever experience
    Flakiness?Redness?Tightness?Excessive oily shine during day?

    What is your present skin regimen?
    Soap and water onlyMoisturizerCleanserExfoliationTonerSun Block every dayMasqueOther

    Other

    Are you ever exposed to chemicals, oils, or other caustic substances that may aggravate your skin?YesNo

    If yes, what are they?

    Do you blush easily? YesNo

    If yes, what are the contributing factors? EmotionsFoodsTemperature changesOther

    Other

    Do you Sun bathe?Use a tanning bed?

    How often?

    Have you ever had PeelsMicrodermabrasionFacial surgeryCosmetic SurgeryBotoxCollagen InjectionsLaser resurfacing

    How recently?

    Are you under treatment for any current skin condition? YesNo

    If yes, what?

    Does your skin heal FastScarsPigments

    Do you bruise easily? YesNo

    Do you get sores/blisters (Herpes Zoster/Shingles)? YesNo

    What medications/hormone replacement/vitamins do you presently take?

    Have you ever used Accutane©Retin-A®Renova®Topical AntibioticsDifferinTazaracHydroquinoneAlpha Hydroxy Acids

    If yes, when and for how long?

    Any personal or family history of skin cancer? YesNo

    Provide detail

    How would you describe your overall health? ExcellentGoodFairPoor

    Have you had any of the following, past or present?

    Acne YesNo
    When
    Allergies YesNo
    Arthritis or Bursitis YesNo
    Blood Pressure HighLowNormal
    Breast Implant YesNo
    Cancer YesNo
    CataractsYesNo
    Cholesterol HighLowNormal
    Claustrophobic YesNo
    Diabetes YesNo
    Diarrhea/constipation YesNo
    Eczema YesNo
    Where
    Epilepsy YesNo
    Hay Fever YesNo
    Headaches YesNo
    How Often
    Heart Disease/Conditions YesNo
    What
    Hepatitis YesNo
    HIV/AIDS YesNo
    Infections YesNo
    Lupus YesNo
    Menopausal YesNo
    Metal Implants YesNo
    Pace Maker YesNo
    Phlebitis YesNo
    Serious Injury YesNo
    What
    Sleep problems YesNo
    Thyroid HighLowNormal
    Varicose Veins YesNo
    Do you smoke? YesNo
    Do you wear contact lenses? YesNo

    Have you ever had a reaction to CosmeticsMetalsMedicationFoodFragranceAirborne particlesOther
    Explain

    FOR WOMEN:

    Oral contraceptives? YesNo
    Are you pregnant or trying to get pregnant? YesNo
    Are you taking hormone replacement? YesNo
    Do you experience hormone imbalances? YesNo

    FOR MEN:

    Do you shave with Electric shaver?Razor?
    Do you experience skin breakouts? YesNo
    Do you have ingrown hair? YesNo

    LIFESTYLE & DIET

    Is your stress level HighMediumLow
    Do you normally sleep well? YesNo
    Do you regularly exercise? YesNo
    Do you have food intolerances? YesNo
    Do you follow any special diet? YesNo

    How many glasses of water do you consume daily?

    How many cups of caffeine-type beverage (coffee, tea, soft drinks) do you consume daily?
    1 - 3 cups4 or more

    In our treatment program, it may be necessary to recommend alterations to or additions in your home care regimen; would that be OK with you?
    YesNo

    Your practitioner will recommend the appropriate schedule for future facial treatments or physician referral in order to achieve your skin improvement goals.

    INFORMED CONSENT RELEASE

    I , do fully understand all the questions above and have answered them all correctly and honestly. I understand that the services offered are not a substitute for medical care. I understand that the skin care professional will completely inform me of what to expect in the course of treatment and will recommend adjustments to my regimen if deemed necessary. I also am aware that individual results are dependent upon my age, skin condition, and lifestyle. I agree to actively participate in following appointment schedules and home care procedures to the best of my ability, so that I may obtain maximum effectiveness. In the event that I may have additional questions or concerns regarding my treatment or suggested home product routine, I will inform my skin care professional immediately. I release and hold harmless the skin care professional, Lorraine ‘RAIN’ Tabraham-Winter, LMT, Esthetician, SET, CFT, CPT; Rain's Therapeutic Massage & Skin Care, Inc., and the staff harmless from any liability for adverse reactions that may result from this treatment.

    POLICIES

    1.We require 48-hours notice for cancellations. Cancellation for Monday must be phoned in on the Friday before.
    2.If you are not satisfied with your service or products, please contact your skin care professional within 24-hours after your appointment so that the situation may be corrected. It is our policy to provide you with the best professional service and products customized for your skin condition.