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CLIENT CONSULTATION CARD

Your Health

Within the last year, have you been under a dermatologist’s or other physician’s care? YESNO
If yes, please specify
Have you had any health problems in the past or present? YESNO
If yes, please specify
List any medications, supplements, vitamins, diuretics, slimming pills, Isotretinoin, etc. That you take regularly:
Do you smoke? YESNO
Do you exercise regularly? YESNO
Do you follow a restricted diet? YESNO
Do you wear contact lenses? YESNO
Do you have metal implants, a pacemaker or body piercings? YESNO
Rate your level of stress on a scale of 1 to 5 (1= Low stress, 5 = High stress)
Do you have any allergies? YESNO
If yes, please specify

Do you sunbathe or use tanning beds? YESNO
Do you drink more than 4 caffeinated beverages daily (coffee, tea, soft drinks)? YESNO
Have you ever experienced claustrophobia? YESNO

Your Skin

What are your specific concerns/challenges with your skin?
What skin care products are you currently using? FACE: Soap Cleanser Toner Moisturizer Masque Exfoliator Eye Products
BODY Soap Shower Gel Scrubs Oil Body Moisturizer Depilatory Products Self Tanners
Have you ever had chemical peels, Microdermabrasion, or any resurfacing treatments? YESNO
In the last month? YESNO
Do you use Retin-A, Renova, Adapalene or any other prescription skin products? YESNO
In the last 3 months? YESNO
Are you currently using any products that contain the following ingredients? Glycolic Acid Lactic Acid Any exfoliating Scrubs Any Hydroxy Acid Product ) vitamin a derivatives (i.e., Retinol)
Do you ever experience these conditions on your skin? Flakiness Tightness Obvious Dryness
What SPF sunscreen do you use on your face? Body?
Do you burn easily in moderate sunlight? YESNO
Do you have a tendency to redness? YESNO
Do you suffer from sinus problems? YESNO
Do you ever experience burning, itching or stinging sensations on your skin? YESNO

Female Clients Only

Are you currently taking contraception? YESNO
Are you pregnant or trying to become pregnant? YESNO
Are you lactating? YESNO
Are you currently having or due for your menstrual period? YESNO

Male Clients Only

Do you have any shaving challenges? YESNO

Questions To discuss Every Visit

Have you started any new medication since your last visit? YESNO

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. AGREE

This consultation card is used to evaluate your individual skin care needs. We will maintain the confidentiality of this information, and will disclose this information only: (1) to our staff members, (2) to quality assurance and quality control personnel, (3) to our product supplier and manufacturer. We will not provide this information to anyone else, except as required by law, and we will not sell this information to anyone. We may, however, contact you with product-related information.

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Timestamp

Audit

June 27, 2021 2:16 pm CDT

CLIENT CONSULTATION CARD Uploaded by DuVall Adminitrative Staff - haleigh@haleighlenz.com IP 75.8.107.116

September 30, 2021 10:30 pm CDT

DuVall Front Desk - front_desk@duvallschool.com added by DuVall Adminitrative Staff - haleigh@haleighlenz.com as a CC'd Recipient Ip: 47.24.68.104

September 30, 2021 10:30 pm CDT

DuVall Appointments - appointments@duvallschool.com added by DuVall Adminitrative Staff - haleigh@haleighlenz.com as a CC'd Recipient Ip: 47.24.68.104

September 30, 2021 10:30 pm CDT

DuVall Education - education@duvallschool.com added by DuVall Adminitrative Staff - haleigh@haleighlenz.com as a CC'd Recipient Ip: 47.24.68.104