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Name:___________________________________DOB:__________________ Age:_____ Sex:______ Address:___________________________________________________________________________ City:_____________________________________ State:____________ Zip:____________ Phone:_____________________ Email:__________________________________________ About You:
• Do you consider your skin (circle the best option): Sensitive / Resilient / Unsure • Describe your skin (circle all the apply): Normal / Dry / T-Zone/Combination / Thick / Thin / Saggy / Firm / Oily / Acne / Comedones/Blackheads / Milia / Cysts / Breakouts / Acne- scarred / Large pores / Small pores / Rosacea / Eczema / Freckled / Sun-damaged / Melasma / Hyperpigmentation / Hypopigmentation / Uneven/Blotchy / Mature / Wrinkled / Patchy dryness / Sallow / Psoriasis / Dehydrated/Lacking moisture / Asphyxiated / Telangiectasia /Broken surface capillaries • What are the changes you’d most like to see in your skin?______________________________________________________________________________________________________________ Lifestyle:
• Are you pregnant or lactating? No Yes(Please consult with your obstetrician. Only the Oxygenating Trio,® Detox Gel Deep Pore Treatment or Hydrate: Therapeutic Oat Milk Mask are appropriate.) • Do you wear contact lenses? No Yes (Remove contacts if eyes are sensitive or if having microdermabrasion.) • Do you currently have a sunburned/windburned/red face? No Yes Why?____________________________________• Are you in the habit of going to tanning booths? No Yes (If within past 14 days, decline treatment. This practice should be discontinued due to increased risk of skin cancer and signs of aging.) • Do you participate in vigorous aerobic activity or sports? No Yes What type?_______________________________ • Do you smoke or use tobacco? No Yes• What kind of work do you do? _______________________________ • On average, how many hours per week do you spend outdoors? ________________________ Medical/Treatment History:
• Do you currently use depillatories or wax? No Yes
(Discontinue use five days pre- and post-treatment.)
• Have you had a chemical peel or any type of procedure with a medical device? No Yes
Within the last 14 days? No Yes
What type? _______________________________
• Do you have regular collagen, Botox® or other dermal filler injections? No Yes (Peels should precede or follow injections by two days to prevent movement of the filler or stinging at the injection site.) • Have you recently had laser resurfacing or facial surgery? No YesDescribe _________________________________ When?___________________________________• Are you currently taking any medications, topical or otherwise? No Yes (Tretinoin/Retin-A®/Renova®/Differin®/Tazorac®/Avage®/ EpiDuo™/Ziana®)Which one(s)? ____________________________ For how long? ____________________________What strength? ___________________________ (High percentages of certain ingredients may increase sensitivity. Discontinue use five days before and after treatment. Consult your physician before discontinuing use of any prescription.)• Are you currently using any topical retinoid prescriptions? No Yes • Have you ever undergone Accutane® therapy (isotretinoin)? No Yes(If you are currently using Accutane® therapy (isotretinoin), please consult with your dispensing physician.)(If you are no longer using Accutane® therapy (isotretinoin) it is OK to apply ONE layer of Ultra Peel® I, Sensi Peel,® Ultra Peel® II, Esthetique Peel, Oxy Trio,® Hydrate: Therapeutic Oat Milk Mask or Revitalize: Therapeutic Papaya Mask.) No Yes • Do you develop cold sores/fever blisters? No YesLast breakout? ___________________________ •Are you allergic/sensitive to (circle all that apply) milk / apples / citrus / grapes / aloe vera / aspirin /perfumes / latex / hydroquinone / mushrooms? If any other allergies, what? ______________________________• Have you ever used any other products that caused a bad reaction? No Yes Describe ________________________________ Patient Signature:____________________________________________________ Date:_________________ Clinician Signature:___________________________________________________ Date:_________________

Source: http://www.sparejuvenate.com/wp-content/uploads/2013/08/facial-qa.pdf