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INTRODUCTION My Name or Order # is:  * My E-mail Address is:  * My Telephone Number is:  * My Age Bracket is: under 2121-3031-4041-50over 50 You are interested in a skincare consultation/prescription for which product line?   MEDICAL HISTORY Witihin the past 6 months have you been prescribed medication by a Physician? YesNo Within the past 6 months have you been prescribed medication by a Dermatologist? YesNo Within the last year have you undergone any surgery? YesNo If Yes please specify  * Have you had any of these health problems in the past or present? (Please select) YesNo Cancer Diabetes Epilepsy Heart Problem Hormone Imbalance Spinal Injury Hysterectomy Thyroid Condition Varicose Veins Systemic Disease List any medications supplements vitamins diuretics slimming tablets etc. that you take regurlarly Do you smoke? YesNo Do you excercise regularly? YesNo Do you follow a restricted diet? YesNo Do you have regular sleep paterns? YesNo Do you wear contact lenses? YesNo Do you have metal implants or pacemaker? YesNo   YOUR SKIN With what temperature of water do you cleanse? CoolWarmHot Do you have any special skin problems pertaining to your face or body? YesNo If Yes please specify Are you using any of the following skin care products? (Please Select) YesNo Soap Cleanser Toner Moisturizer Masque Exfoliater Eye Products Other skin care products please specify EXFOLIATION HISTORY Have you ever had chemical peels laser or dermabrasion? YesNo in the last month? Do you use Retin A Renova or Adapalene? YesNo in the last 3 months? YesNo Do you use an acne medication? YesNo in the last 6 months? YesNo If Yes which drug Are you currently using any products that contain the following ingredients? (Please Select) YesNo Glycolic Acid Lactic Acid Any exfoliating scrubs Any hydroxy acid product Vitamin A derivatives (ie.retinol) MOISTURE HYDRATION How much plain water do you consume daily? How many alcoholic beverages do you consume weekly? Do you ever expeience these conditions on your skin? (Please Select) YesNo Flakiness Tightness Obvious Dryness What SPF sunscreen do you use on your face? What SPF sunscreen do you use on your body? Do you sunbathe? YesNo CAPILLARY ACTIVITY Do you burn easily in moderate sunlight? YesNo Do you blush easily when nervous? YesNo Do you have a tendency to redness? YesNo Do you suffer from sinus problems? YesNo OIL SECRETION Do you ever experience oily shine during the day? YesNo Do you ever experience skin breakouts? OccasionallyYesNo NERVE ACTIVITY Do you drink caffeinated beverages (coffee tea soft drinks)? YesNo How many daily? Do you ever experience a burning itching sensation on your skin? YesNo What is your pain threshold? LowMediumHigh Have you ever experienced claustrophobia? YesNo What type of massage pressure do you prefer? SoftMediumFirm Have you ever had a reaction to any of the following? (Please Select) YesNo Cosmetics Medicine Iodine Pollen Food Hydroxy Acids Animals Fragrance Sunscreens Other (Please Specify) FEMALE CLIENTS ONLY Are you taking oral contraception? YesNo Are you pregnant or trying to become pregnant? YesNo Are you lactating? YesNo MALE CLIENTS ONLY What is your current shaving system? ElectricWet Shave Do you experience irritation from shaving? YesNo Do you experience ingrown hairs? YesNo CONCLUSION I confirm (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. YesNo Please provide us with any additional information here: Security code:   * Do not enter anything in this field: