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Comprehensive Skin Analysis Form
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Skin History
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What are your main skin concerns?
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Which Skin conditions do you want to treat?
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Are you currently receiving treatment from a Dermatologist?
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If yes, explain:
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Are you currently using any form of topical Vitamin A/Retinol/Retin-A?
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Have you been on Accutane the past 6 months?
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Have you received a facial before?
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Are you using any Professional grade skincare?
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If yes, what kind?
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If yes, when?
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Are you currently using any forms of AHA or BHA?
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If yes, please explain:
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How would you describe your skin?
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Current skin regimen?
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How does your skin respond to sun exposure?
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Do you turn red easily?
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If yes, what may contribute?
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Reaction to Sun exposure:
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What is your ethnic background?
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Do you work outdoors?
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Are exposed to caustic substances that may aggravate your skin?
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Do you sun tan or use a tanning bed?
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If yes, how often?
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Do you scar easily?
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Do you bruise easily?
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Medical Concerns
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Are you currently on any medications, hormone therapy, anti-inflammatories, aspirin, or blood thinners?
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If not listed, please explain:
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Female
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Are you pregnant or trying to get pregnant?
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Nursing or breastfeeding?
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Currently taking any form of contraceptives?
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Experiencing hormonal imbalances?
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Male
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Currently on any form of hormone replacement therapy?
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Experience ingrown hairs?
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Additional skin concerns?
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Allergy/Sensitivities
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Do you have any contact allergy or sensitivity to any of the following:
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If not listed, please explain:
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Allergy to stainless/carbon steel?
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Have you had any in the past or present?
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Arthritis or Bursitis
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Eczema
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Extremely High/Low blood pressure
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Epilepsy
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Breast implants?
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Hay fever
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Cancer
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Headaches
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Abnormal Cholesterol level
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Heart conditions
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Claustrophobia
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HIV/AIDS
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Cold Sores
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Infection
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Dermatitis
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Lupus
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Diabetes
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Metal pins/Implants
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Pacemaker
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Phlebitis
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Abnormal Thyroid
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Serious Injury
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Lifestyle & Diet
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Do you smoke any of the following:
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Do you wear contact lenses?
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Dietary or Food Intolerances?
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Gluten/Wheat
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Nightshades (Tomato, Potato, Eggplant)
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Dairy Products
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Nuts
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Eggs
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Shellfish
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Fruit
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Soy
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Seafood
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Whey
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Other:
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Do you sleep well/enough?
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Do you regularly exercise?
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Describe your current hydration levels
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Do you regularly consume caffeine?
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