Skincare Intake Form Book Your Facial Here. Name * First Name Last Name Email * Phone * (###) ### #### DOB MM DD YYYY Zip Code How did you hear about us? Referred to: YOUR SKIN What is your #1 skin goal? What is your #1 skin challenge? When did this concern start for you? Do you have a hunch about what could be causing it? What do you hope to achieve through our work together? Wellness and Medical Safety Please list any and all allergies (including food and seasonal) Please list any medications, vitamins, and supplements you're currently taking Do you follow a specific diet? Do you have any known food sensitivity? How many glasses of water do you drink daily? 1 - 3 4 - 6 7 - 9 10+ What is your current stress level? Low: 1 - 3 Moderate: 4 - 6 High: 7 - 9 Profound: 10+ Please select any of the following that apply to you: Diabeties Epilepsy Cancer HIV Immune System Condition [Lupus, Chronic Fatigue, Hashimotos, etc.) Digestive Condition [IBS, Chrons, Colitis, etc.] Thyroid Condition [Hypo or Hyper] Recent Surgery Recent Antibiotics Recent Dental X-Ray None Please select all that apply: Are you pregnant? Trying to become pregnant? Are you breastfeeding? Have you recently had a change in birth control? Other hormone-related experience? None Any hormonal therapy related to the above? Are you under the care of a dermatologist? Yes No Used to be Did they prescribe anything? Do you currently use any topical medications? (regularly or occasionally) Have you had Botox, or any other injections? Yes No If so, how recently? Do you have any other consistent self care rituals? Thank you!
