Michelle's Hidden Spa Skincare Intake Form

Michelle's Hidden Spa

Skin History Questionnaire and Waiver Form
Date

Month Day Year
Date
Name

First Name Last Name
Referred By
Google, Yelp, Facebook, etc.
E-mail Address
Birth Date

Month Day Year
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
How is your general health?

Excellent Good Fair Poor
Do you have any medical conditions?

Yes No
Please describe all conditions
Are you currently taking any medications?

Yes No
Please list all medications
Have you ever had a cold sore/fever blister?

Yes No
Do you have one now?

Yes No
Do you have any allergies or skincare ingredient sensitivities?

Yes No
Please list all allergies or sensitivities
Are you currently using any prescription skin care products or topical antibiotics?

Yes No
Please list all products
Please check any that you are currently using or have used in the past:

Glycolic Acid (AHA) Salicylic Acid (BHA) Lactic Acid (AHA) Resorcinol Retin -A None
Which skin type best describes your skin?

Balanced Oily Combination Dry
Please check all skin care concerns you currently have

Oiliness Visible Pores Blackheads Acne Breakouts Cystic Acne Scarring Inflammation Redness Sensitivity Dryness Sun Damage Flakiness Wrinkles Discoloration Uneven Texture Dullness Sagging Roughness Itchiness Puffiness Broken Capillaries Eczema Psoriasis Rosacea

When do you wash your face?

Whenever Morning Evening Morning & Evening
Do you wear makeup?

Every Day Sometimes Rarely Never
Do you always remove your makeup before going to bed?

Always Usually Rarely Never
How often do you exfoliate?

Every Day Weekly Rarely Never
How often do you wear sunscreen?

Always Sometimes Rarely Never
Please check all skin care products that you use

Cleanser Facial Oil Bar Soap Exfoliant Toner/Astringent Moisturizer Eye Cream Night Cream Day Cream Treatment Mask Enzyme Peel Sunscreen
List skincare brands that you use

How many glasses of water (8oz.) do you usually drink per day?

	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16

1 is , 16 is

How many hours of sleep do you usually get per night?

	1	2	3	4	5	6	7	8	9	10

1 is , 10 is

How are your stress levels?

	1	2	3	4	5

1 is Mild, 5 is Severe

Do you regularly do any of the following?

Use a Tanning Bed Smoke Cigarettes Eat Highly Processed Foods Drink Alcoholic Beverages Drink Caffeinated Beverages
Is there any other necessary information your Esthetician should know before beginning your treatment?

Yes No
Please Explain
I understand that facials, peels, microdermabrasion and all other treatments have a risk of skin irritation, rash, burning sensation, etc. The use of organic products does not guarantee that a reaction won’t occur. All facials run a risk of allergic reactions. I understand that Same Day Cancellations and No-Shows will be charged 100% of the service. If I can fill this spot your card will not be charged. If this is your first same day cancellation, card will be charged but the credit can be used for a future appointment. The future appointment must not be canceled. Gift Certificates will be forfeited for Same Day Cancellations and No-Shows. If I can fill this spot you will not forfeit your gift certificate. I have carefully read and understand all of the above and I have answered all questions fully and accurately. *

Signature Date
Thank you for completing the form. Please silence your cell phone and enjoy your treatment!
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm