DuVall's School of Cosmetology

CLIENT CONSULTATION CARD


Your Health

  1. Within the last year, have you been under a dermatologist’s or other physician’s care?
    If yes, please specify  
  2. Have you had any health problems in the past or present?
    If yes, please specify  
  3. List any medications, supplements, vitamins, diuretics, slimming pills, Isotretinoin, etc. That you take regularly:  
  4. Do you smoke?
     
  5. Do you exercise regularly?
     
  6. Do you follow a restricted diet?
     
  7. Do you wear contact lenses?
     
  8. Do you have metal implants, a pacemaker or body piercings?
     
  9. Rate your level of stress on a scale of 1 to 5 (1= Low stress, 5 = High stress)  
  10. Do you have any allergies?
      If yes, please specify
  1. Do you sunbathe or use tanning beds?
     
  2. Do you drink more than 4 caffeinated beverages daily (coffee, tea, soft drinks)?
     
  3. Have you ever experienced claustrophobia?
     

 

Your Skin

  1. What are your specific concerns/challenges with your skin?  
  2. What skin care products are you currently using? FACE:
    BODY
     
  3. Have you ever had chemical peels, Microdermabrasion, or any resurfacing treatments? 
    In the last month?
     
  4. Do you use Retin-A, Renova, Adapalene or any other prescription skin products?
    In the last 3 months?
     
  5. Are you currently using any products that contain the following ingredients?
  6. Do you ever experience these conditions on your skin?
  7. What SPF sunscreen do you use on your face? Body?  
  8. Do you burn easily in moderate sunlight?
     
  9. Do you have a tendency to redness?
     
  10. Do you suffer from sinus problems?
     
  11. Do you ever experience burning, itching or stinging sensations on your skin?
     

Female Clients Only

  1. Are you currently taking contraception?
     
  2. Are you pregnant or trying to become pregnant?
     
  3. Are you lactating?
     
  4. Are you currently having or due for your menstrual period?
     

Male Clients Only

  1. Do you have any shaving challenges?
     

Questions To discuss Every Visit

  1. Have you started any new medication since your last visit?
     

 

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.

 

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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Signature Certificate
Document name: CLIENT CONSULTATION CARD
lock iconUnique Document ID: 35a13d56546a31bf50e4ca51fffff534c646ed21
Timestamp Audit
June 27, 2021 2:16 pm CSTCLIENT CONSULTATION CARD Uploaded by DuVall Adminitrative Staff - [email protected] IP 47.24.68.104
September 30, 2021 10:30 pm CSTDuVall Front Desk - [email protected] added by DuVall Adminitrative Staff - [email protected] as a CC'd Recipient Ip: 47.24.68.104
September 30, 2021 10:30 pm CSTDuVall Appointments - [email protected] added by DuVall Adminitrative Staff - [email protected] as a CC'd Recipient Ip: 47.24.68.104
September 30, 2021 10:30 pm CSTDuVall Education - [email protected] added by DuVall Adminitrative Staff - [email protected] as a CC'd Recipient Ip: 47.24.68.104