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Microdermabrasion Assessment

First Name:	Last Name:
Email Address:	Date:

CLIENT ANSWER QUESTIONS 1-5

1. Have you had any cosmetic surgeries, laser resurfacing, chemical peels, or dermabrasion?

If yes, when?

YesNo

2. Have you had any recent injectables, fillers, or botox?

If yes, when?

YesNo

3. Do you use Retin-A, other vitamin A products, or other medications that exfoliate or thin the skin?

YesNo

4. Are you currently on any photosensitizing medications?

YesNo

STUDENT FILL OUT THE PORTION BELOW

Skin Type and Aging:

___ Fitzpatrick I

___ Fitzpatrick II

___ Fitzpatrick III

___ Fitzpatrick IV

___Fitzpatrick V

___Fitzpatrick VI

___ Rubin I

___ Rubin II

___ Rubin III

Skin Conditions:

___ Telangiectasias	Improved since last treatment? __Yes __No
___ Wrinkles	Improved since last treatment? __Yes __No
___ Scarring	Improved since last treatment? __Yes __No
___ Rough Texture or Solar Damage	Improved since last treatment? __Yes __No
___ Hyperpigmentation	Improved since last treatment? __Yes __No
___ Acne	Improved since last treatment? __Yes __No

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June 16, 2021 11:37 pm CST

Microdermabrasion Assessment Uploaded by DuVall Adminitrative Staff - haleigh@haleighlenz.com IP 47.24.68.104