Client Questionnaire

Name:                                                     Date of Birth:
Address:
Contact phone number:
Are you on any medications or over the counter herbal supplements?
NO              YES   (Please list):
Have you ever had any cosmetic treatments that have been less than satisfactory?
NO              YES   Please state the reasons:
Do you have any ALLERGIES or any severe allergic reactions?
NO              YES   Please list allergies:
Have you been told that you suffer from the following:
-Eaten Lambert Syndrome            Yes   No
-Multiple Sclerosis                        Yes   No
-Bleeding disorder                         Yes   No
-Skin conditions         No    Yes    If Yes, please list:
Have you ever had COLD SORES?         N  /  Y
Have you been treated with ROACCUTANE for acne in the last 6 months?  N /Y
Have you had deep chemical peels or laser skin resurfacing in the past 6 months? N/Y
Have you had surgery or trauma or scarring to your face?   N / Y
Are you on Vitamin E, Fish oil, Aspirin, Evening primose oil?    N / Y
For Female clients: any chance you may be pregnant, planning to become pregnant or breastfeeding? N / Y
Reason for visit today:
Signature:
Date:            /           /   20 ____