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Client Intake Form-Facials

Birthday
Month
Day
Year
How would you describe your skin?
Oily
Sensitive
Dry
Normal
Combination
Have you ever received the following procedures?
What skincare products do you use on a daily basis?
Have you used any of the following topical/ oral dermatological medications?
Are you currently taking birth control pills or have an IUD?
Yes
No
Are you currently pregnant or breastfeeding?
Yes
No
Are you currently experiencing Perimenopause or Menopause?
Yes
No
Are you currently undergoing any hormone therapies or taking infertility medications?
Yes
No
How often do you consume alcohol?
Often
Sometimes
Rarely
Never
How often do you consume caffeine?
Often
Sometimes
Rarely
Never
How often do you consume tobacco?
Often
Sometimes
Rarely
Never
How often do you consume marijuana?
Often
Sometimes
Rarely
Never
How often do you consume water?
Often
Sometimes
Rarely
Never
How often do you consume sugar?
Often
Sometimes
Rarely
Never
Are you having atleast one bowel movement a day?
Yes
No
Have you had excessive sun exposure in the last few days?
Yes
No
Will you be having excessive sun exposure on vacation or in the near future?
Yes
No
Are you in the habit of using tanning booths?
Yes
No

Medical History

Have you ever had any of the following conditions?
Do you have any other medical concern that has not been covered in this form?
Yes
No
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