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Skin & Health Questionnaire

Please answer the following questionnaire thoroughly and completely, as this provides a better understanding of your general health, lifestyle, and skincare concerns; thereby enabling the best skin care program to be customized for your individual needs.

Skin Care History

What else? Please check all that apply
What type of skin do you think you have?
If oily, are you oily throughout the cheek area?
Do you have a history of acne?
If yes, are you using or have ever used any medication for acne?
Do you sunbathe or participate in outdoor activities?
Do you get claustrophobic?
Have you ever had a reaction to any skin care product or comestic?
Please check if you are currently usng or have used any of the followng:
Have you ever, or are you currently receiving skin services?
Have you had any of the Following?

General Health

Are you currently under the care of a physician?

If yes, please discuss contraindications of any pre-existing medical conditions with your physician.

Are you currently taking any medication?

Female Clients

Are you on hormone- replacement therapy?
Are you currently taking birth control pills?
Are you pregnant or breast feeding?
Please check the following conditions you have, or have had in the service are:
Are you allergic to aspirin?
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