CONFIDENTIAL SKIN CARE QUESTIONAIRE

Your Name (required)

Phone number

Date of Birth

Dermatologist / Physician

Emergency Contact

Your Email (required)

Address

Occupation

Dermatologist / Physician Phone

Emergency Contact Phone

EXPECTATIONS & HISTORY

1. Which conditions would you like to improve?
Acne ScaringEnlarged PoresBroken CapillariesOtherAcneFine Lines & WrinklesStretch MarksAge SpotsHyperpigmentationSurgical / Facial Scars

If other, please explain

2. Have you ever had facial treatments in the past?
YesNo

What was your experience?

3. How would you describe your skin?
NormalDryOilyCombinationSensitiveSun Damaged

4. How would you rate your skin?

5. Do you experience
Flakiness?Dryness?Redness?Excessive Oily Shine During Day?

6. What is your present skin regimen?
Soap & water onlyCleanserTonerMaskMoisturizerExfoliationSun block every dayOther

If other, please explain

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

If yes, what are they?

8. Do you blush easily?
YesNo

If yes, what are the contributing factors?
EmotionsTemperature changesFoodsOther

9. Do you sunbathe or use a tanning bed?
YesNo

If yes, which and how often?

10. Have you ever had
PeelsMicrodermabrasionFacial surgeryCosmetic surgeryBotoxLaser resurfacingCollagen injectionsNone of these

If any, how recently?

11. Are you under treatment for any skin condition?
YesNo

If yes, what?

12. How does your skin heel?

13. Do you bruise easily
YesNo

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

15. What medications / hormone replacements / vitamins do you currently take?

16. Have you ever used any of the following medications?
DifferinTazaracRenovaAlpha Hydroxy AcidsAccutaneRetin-ATopical AntibioticsHydorquinoneNone of these

If yes, when and how long?

17. Any personal or family history of skin cancer?
YesNo

If yes, please provide details

18. How would you describe your overall health?

19. Have you ever had any of the following?

Acne
YesNo

If yes, when?

Allergies
YesNo

Arthritis or Bursitis
YesNo

Blood Pressure Reading
HighNormalLow

Breast Implants
YesNo

Cancer
YesNo

Cataracs
YesNo

Cholestorol Screening
HighNormalLow

Claustrophobic
YesNo

Diabetes
YesNo

Diarrhea / Constipation
YesNo

Eczema
YesNo

Epilepsy
YesNo

Hay Feaver
YesNo

Headaches
YesNo

If yes, how often?

Heart problems
YesNo

If yes, what?

Hepatitis
YesNo

HIV / AIDS
YesNo

Infections
YesNo

Menopausal
YesNo

Metal Implants
YesNo

Pace Maker
YesNo

Phelbitis
YesNo

Serious Injury
YesNo

If yes, what?

Sleep Problems
YesNo

Thyroid Screening
HighNormalLow

Varicose Veins
YesNo

Do you smoke?
YesNo

Do you wear contact lenses?
YesNo

20. Have you ever had a reaction to
CosmeticsMetalsMedicationFoodFragranceAirborne ParticlesOther

If other, please explain

21. FOR WOMEN

Taking oral contraceptives?
YesNo

Are you pregnant or trying to become pregnant?
YesNo

Are you taking hormone replacement?
YesNo

Do you experience hormone imbalances?
YesNo

22. FOR MEN

What do you shave with?
Electric ShaverRazor

Do you experience skin breakouts?
YesNo

Do you have ingrown hairs?
YesNo

LIFESTYLE & DIET

1. What is your stress level?
HightMediumLow

2. Do you normally sleep well?
YesNo

3. Do you regularly exercise?
YesNo

4. Do you have food intolerances?
YesNo

If yes, what?

5. Do you follow any special diet?
YesNo

6. How many glasses of water do you consume daily?

7. How many cups of caffeinated beverages ( coffee, tea, soft drinks ) do you consume?

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

INFORMED CONSENT RELEASE

Please Read and Initial

I 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 the aesthetician 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 the 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 suggest home product routine, I will consult with my aesthetician immediately.

I release and hold harmless the aesthetician, Pamela Cato, Cato Advanced Skin Care, and the staff from any liability for adverse reactions that may result from this treatment.
I have read and agree to the terms above *

POLICIES

1. We require 48-hours notice for cancellation. 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 specialist 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.

ELECTRONIC SIGNATURE

I have read and understood all of the forgoing information. Click and drag your mouse in thespace below to sign.