New Client Questionnaire Date MM DD YYYY Name First Name Last Name Birth Date MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email Occuptation/Work Personal Data Pregnant Yes No Cosmetic Surgery Yes No If yes, when Define procedures Health problems? Yes No If yes, explain Do you have any allergies? Yes No Do you use sunscreen? Yes No Please name the brand of products you are currently using: Cleanser Moisturizer Mask Toner Scrub Buff Puff Other Have you ever used Retin-A? Yes No If yes, what strengeth Have you ever been treated with Phenol or Trichloracetic acid? Yes No Have you ever used Hydroquinone (skin lightener)? Yes No Have you ever been on Accutane? Yes No If yes, when? Have you ever had herpes, hives, cold sores, fever blisters, keloids? Yes No If yes, when How would you characterize your skin? Sensitive Rough Oily Dry Acne prone If you had a complaint about your skin what would it be? Describe your skin in three words Additional comments and concerns Thank you!
