Client intake form

CLIENT INTAKE FORM for ESTHETIC CONSULTATION
Name (Please print clearly)___________________________________________________Date____________________ Day/Work #__________________________Home #_________________________Cell #_________________________ Address____________________________________________City_______________________ST_______Zip________ DOB___________________________Age____________Referred by_________________________________________ Email address___________________________________________________Marital Status_______________________ Occupation___________________________________________________Blood type_____________ph level_________ Please fill out as completely as possible. All information will be held in strictest confidence. Please list any prescribed, oral, or topical medications you are currently using, including contraceptives, hormone replacement therapy, allergy medications, acne treatments, etc. Medication_____________________________________! Side Effects___________________________________ ______________________________________________! _____________________________________________ ______________________________________________! _____________________________________________ Are you currently seeing a dermatologist?________Dermatologist name and #__________________________________ For what conditions?__________________What medications/treatments have been prescribed?____________________ Do you cleanse your complexion before retiring? Every night religiously_______Occasionally miss______Never_______ What are your personal goals for your skin?______________________________________________________________ Please tell me about your home skincare regime including brands of products: Makeup Remover__________________________________! How removed ?(Tissue, Washcloth, Hands, Other) Cleanser AM______________________________________! Cleanser PM__________________________________ Toner____________________________________________! Masques______________________________________ Moisturizer AM_____________________________________! Moisturizer PM_________________________________ Eye Creme________________________________________! Neck Creme___________________________________ Sunscreen_________________________________________! Skin Lighteners________________________________ Acne Products______________________________________! Glycolic Acids__________________________________ Clarisonic Skin System_______________________________! Other________________________________________ CLIENT INTAKE FORM for ESTHETIC CONSULTATION
HAVE YOU EVER USED ANY OF THE FOLLOWING TOPICALS?! Have you experienced allergic reactions or irritations to any skin care product or procedure?________________________ If yes, please describe in detail________________________________________________________________________ Please check any of your skin care concerns: _____! Other______________________________________________________________________________________ Hours per week!_____! Hours of sleep daily_______________________ Water consumption daily____________Kind of water_________!! Cups of coffee/tea daily____________________ Soda consumption per day_________________ Graveyard/swing shift________!For how long____________ ! Diet soda/Nutrasweet per day_______________ Daily sun exposure______Hours____________! ! Fast food consumption daily________________ Work near chemicals?! For how long___________! Eat salty foods/cheese daily________________ Phone usage____________ Hours per day___________! Amt of alcohol consumption daily____________ Use tanning bed______Times per week_______!_______! Reuse washcloth on complexion! ?___________ Do you smoke?______Use drugs______Type______________! ! Change pillow case how often?! ____________ CLIENT INTAKE FORM for ESTHETIC CONSULTATION
_____! I feel positive, confident, flexible and easygoing_____! I tend to become negative, obsessive, worried and sleepless_____! I am energized, upbeat and alert_____! I can sink into a flat, lethargic funk_____! I am relaxed and stress-free_____! I am wired, stressed and overwhelmed_____! I am full of cozy feelings of comfort, pleasure and euphoria_____! At times, I feel I could cry at commercials and am overly sensitive to hurt Please answer as accurately and honestly as possible.
I exercise_______________times per week. __________Aerobic__________Wt Resistance________Yoga___________ My stress level I experience daily is Minimal________________Somewhat__________________High________________ I move my bowels Daily______Times per day_______Every other day________Other____________________________ I experience gas and/or bloating?_________If yes, what foods seem to trigger discomfort__________________________ I have food cravings?________ If yes, to what kinds of foods? Sweets______Salty______Chocolate______Dairy______ I have a pace maker?______Artificial heart valve?______Artificial joint?______I am wearing contact lenses?__________ I have bleeding problems?_________High blood pressure?__________Diabetes?____________Hypoglycemia?_______ I have________ colds per year. I have_________sore throats or strep per year. I have sinus issues ________________ I have elevated cholesterol___________My numbers are________________I have elevated triglycerides?____________ I am currently dieting__________I have difficulty losing weight_____________I think I am an emotional eater__________ My trigger issues/foods are_______________________________________________I have allergies to latex__________ I struggle with yeast/candida issues_________I have allergies to_____________________________________________ I lack mental clarity, at times_______________I am allergic to aspirin__________________________________________ For women only: Please check any that apply:
_______How severe? Mild__________Moderate__________Severe__________ Date of last shot?_________________________ For men only: Do you take zinc or any supplements for the prostate?________Do you know your PSA #?_____
CLIENT INTAKE FORM for ESTHETIC CONSULTATION
What is your nationality?_____________________________________________________________________________ Have you performed a saliva test within the past year to know if your hormones are balanced?_____________________ If so, please indicate approximate date_________________________Hormones drive our bodies and balancing hormones is easy and anti-aging. Would you like to perform a hormone test in the near future?_____________________ Please indicate which nutritional supplements you consume on a daily basis including brand and amount:
Vitamin D3_____________________________________ Minerals_______________________________________ Essential Fatty Acids_____________________________ Flax Seed Oil___________________________________ Magnesium____________________________________ MSM_________________________________________ Calcium_______________________________________ Zinc__________________________________________ Multi-Vitamin___________________________________ Protein Shake__________________________________ Probiotics______________________________________ Green Tea_____________________________________ Digestive Enzymes______________________________ Please list any other supplements you are taking not listed above: Is there anything else I need to know about your medical background that may be necessary for me to know before I treat you? Please explain in detail.

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