Facial Intake Form | Aesthetics by Cathy

First name

Last name

Address

Phone

Email

Natural eye color:

Natural hair color

Do you consider your skin to be

Sensitive

Resilient

Unsure

Describe your skin (check all that apply)

What changes would you most like to see in your skin?

Are you pregnant or lactating?

No

Yes (please consult with your obstetrician)

Do you wear contact lenses?

Yes

No

Are you currently sunburned/windburned/red face?

Yes

No

Are you in the habit of going to a tanning booth?

Yes

No

Do you participate in vigorous aerobic activity or sports?

Yes

No

Do you smoke or use tobacco?

Yes

No

What kind of work do you do?

On average, how many hours per week do you spend outdoors?

Do you currently use depilatories or wax?

Yes

No

Have you had a chemical peel or any type of procedure with a medical device?

Yes

No

If yes, was it within the last 14 Days? What type of procedure?

Do you have regular collegan, Botox, or other dermal filler injections?

Have you recently had laser resurfacing or facial surgery? Describe and when?

Are you currently taking and medications, topical or otherwise? (Tretinoin/Retin-A/Renova/Differin/Tazorac/Avage/EpiDuo/Ziana Which ones? For how long? What strength?

Have you ever undergone Accutane therapy? (isotretinoin)?

Do you develop cold sores/fever blisters? Last breakout?

Are you allergic/sensitive to any of the following?

Any other allergies?

Have you ever used any other products that caused a bad reaction? Describe

Date

Month

Day

Year

Signature

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