Face Reality Client Questionnaire Your Information Client Name First Name Last Name Date of Birth - Month - Day Year Date Guardian Name First Name Last Name Ethnicity Address Street Address Street Address Line 2 City State / Province Postal / Zip Code Phone Number Please enter a valid phone number. Email example@example.com Medications, place an x where it applies * When How Long Antibiotics Androstendione Accutane Testosterone Benzoyl Peroxide Progesterone Retin A Thyroid Cream or Gel? Gonadotrophin Tazorac Danzol Differin Cyclosporin Azelex Lithium Avita Isoniazid Cleocin-T Immuran E-mycin-T Disulfuram Copaxone Dilantin/Tegretol Corticosteroids Steroids Quinine Marijuana Cocaine/Speed Other Meds No medication Medical History (please check all that apply) * History of: Herpes Simplex HIV/AIDS Hemophilia Eczema Thyroid Problems Lupus Psoriasis Hormone Problems Anemia Hepatitis Hysterectomy High Blood Pressure Cancer Ovary(ies) Removed Diabetes Staph Infection/MRSA Pacemaker Metal Pins in Body None of the above Your Primary Care Physician: Name First Name Last Name Physician Phone Number Please enter a valid phone number. Are you under a dermatologist’s or other physician’s care? Yes No If yes, doctor’s name: Lifestyle Considerations Have you ever had any reaction to any products or anything you have put on your face? Yes No If yes, what products? Please check any of these you are allergic to: Sulfur Aspirin Latex List any other allergies you know of: Do you smoke? Yes No Do you use fabric softener or fabric softener sheets in the dryer? Yes No Do you swim in a chlorinated pool? Yes No Do you work around chemicals, tars, oils, grease or inks? Yes No Occupation: Do you work nights? Yes No Are you currently under a lot of stress?(common stress = job loss, new job, wedding, romantic breakup, death in the family or close friend, graduation, difficult home life, long commute, heavily scheduled) Yes No Women: Do you use birth control pills, shots or use an IUD? Yes No If so, which do you use? What brand of pill? Are you pregnant or nursing? Yes No Men: Do you have shaving irritation? Yes No What type of razor do you use for shaving? Diet- Do you consume the following? (place and x if it applies) How Often per week Fast Food Peanuts Processed Food Sushi Salty Snacks Kelp and Seaweed Milk/Yogurt Miso Soup Cheese Soy Whey or Soy Protein Vitamins Peanut Butter Seafood None of the above Products Currently Using Please Provide Product Names Product Name Cleanser Toner Serums Moisturizers Sunscreen Mask Foundation Blush Exfoliant (acids, serums, scrubs) Acne Medications Anything Else? Other Treatments: What else have you done for your skin in the last 90 days? * When? Where? Chemical Peels If so, what kind: Microdermabrasion Dermabrasion Laser Hair Removal Laser Rejuvenation/Resurfacing Skin Cancer Removal Facial Waxing Electrolysis Other: How did you hear about us? Submit Should be Empty:
