1Personal Information

    Name:

    Phone:

    Email:

    Address:

    City:

    Zip:

    2Medical History

    The following information is needed to ensure your well_being during a treatment or consultation for a custom regimen. It is important for me to know of any conditions that may cause a reaction from a treatment. All information will be kept confidential. Each condition will influence how I perform a treatment or decide to recommend a product. Please provide me with extended information if necessary

    Any other medical conditions not listed above to which we need to be aware? Specify Below

    Are you currently under the care of a Physician?
    Are you taking any oral medication? Specify Below

    Have you ever been diagnosed medically with an allergy? If so, specify here

    Have you ever had any other allergic-type reaction to anything you applied to your face?
    Specify Details Below

    Are you currently using or have you in the last 6 months used Accutane?

    In the last 6 months note your stress level 1 2 3 4 5 6 7 8 9 10 Specify Here

    Please check if you are CURRENTLY using any of the following?

    In your own words what concerns, or challenges are you currently trying to overcome with your skin? Specify Below

    Have you noticed any changes in our skin over the last 2-3 weeks? Specify Details Below

    What is your #1 Skincare goal?

    #2 Skincare goal

    Check all that apply:

    3Client Consultation Information

    Gender

    NOTE IF UNDER 18 – MUST HAVE PARENTAL CONSENT SEE SIGNATURES

    Age Group

    Questions about lifestyle

    Do you Smoke?

    Do you burn easily in the sun?

    Do you swim in a chlorinated pool on a regular basis?

    Do you use fabric softener or sheets in the dryer?

    Have you been diagnosed with rosacea or acne rosacea?

    Are you using any hormonal birth control pills, shots, or IUD

    What Kind?

    Do you blush easily?

    Occupation Specify Here

    Do you consume any of the following more than 3X a week? Check all that apply

    Exercise Regimen: Specify Below Time of Day? How many days per week on average?

    Skip if Not Applicable

    Have you seen a Dermatologist or General about Acne?

    What did they
    prescribe?

    How long did you do their recommendations?

    Any Results?

    What Medications or Over the Counter Products Have You Tried in the Past For Acne, Discoloration,
    and/or other issues?

    Antibiotics How long?

    Results:

    Duac How long?

    Results:

    Benzoyl Peroxide How long?

    Results:

    Tea Tree Oil How long?

    Results:

    Salicylic Acid How long

    Results:

    Tazorac How long?

    Results:

    Differin How long?

    Results:

    Azelaic Acid How long?

    Results:

    Sulphur How long?

    Results:

    Retin A/ Tretinoin Cream or Gel How long?

    Results:

    Topical Vitamin C How long?

    Results:

    Alpha Hydroxy How long?

    Results:

    Hydroquinone How long?

    Results:

    Pro Active How long?

    Results:

    Aczone How long?

    Results:

    Epido Forte How long?

    Results:

    Other Oral Vitamins , Medications, or other Topical Prescriptions For Acne, Rosacea, Discoloration, or Anti_Aging? Specify Here:

    What else have you done for your skin:

    Acne History (If not Applicable Skip)

    Did you have puberty acne?

    How long has your acne been an issue?

    Do you know what kind of acne you have?

    Describe Details Below

    How Often do you pick at your skin?

    How bad is your Acne to date? Scale 1 to 10

    How sensitive is your skin on a Scale 1 to 10

    How long does it take for your skin to feel oily after you cleanse in the morning? How many hours?

    Is it oily in T-Zone or All Over?

    I don’t or rarely feel oily?

    How often do you experience break outs?

    Types of blemishes?

    What area of the Face do these appear?

    Skin History

    Do you wear sunscreen everyday no matter what?

    How long have you been doing this?

    Products Currently Using:

    1) Line up your Morning Skincare Products & Take a picture – Also if available take a picture of the ingredient on the back of the bottles.
    2) Line up your Evening Skincare Products & Take a picture – Also if available take a picture
    of the ingredient on the back of the bottles.

    How often do you wear Make-up?

    Make_Up Currently Using / Brand Names if known

    Please send me close-up pictures of all the areas of concern…the closer the better and one
    full face at a distance. Text to me at 408_509_5092 or email at info@beautifyyourskin.com

    Please confirm the answers:

    I have given are correct, and I have not withheld any relevant information. I understand that withholding or providing misinformation may result in a contraindications and/or irritation to my skin. The treatments I receive here are voluntary and recommended or purchased products are used at my own risk. I understand that by signing this waiver, I waive and release any rights to pursue damages against MeMe Glick, Beautify Your Skin Inc, and their employees or affiliates should any side effects occur.

    Please Type your name below to consent that you understand these terms.

    PARENT/GUARDIAN IF UNDER 18

    Date

    Name

    Date

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