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Glow Skin Spa Skin Care Consultation Card

Date Email Address Home Phone Birthday Work Phone Occupation yes yes yes no no no Client Name Client Address City, State, Zip Cell Phone How did you hear about us? If yes, please specify If yes, please specify If yes, please specify Apt.#

Within the last year, have you been under a physician's care? Within the last nine months, have you undergone any surge Have you had any health problems in the past or present?

List any medications, supplements, vitamins, diuretics, slimming tablets, etc. that you take regularly Do you wear contact lenses? yes no Rate your level of stress on a scale of 1 to 4 (1=low stress, 4=high stress)

exfoliation history (please specify for any of the below) Have you ever had chemical peels, microdermabrasion, or any resurfacing treatments? Do you use Accutane, Retin A, Renova, Adapalene or any other prescription skin products? Are you currently using any products that contain any of the following ingredients? (circle those that apply) vitamin A derivatives salicylic acid (i.e. retinol) glycolic acid lactic acid exfoliating scrubs What skin care products are you currently using? (circle those that apply) face body soap soap cleanser shower gel moisturizer scrubs masque oil exfoliator body moisturizer eye products depilatory products self tanner

How much plain water do you consume daily? Do you ever experience these conditions on your skin? Which SPF sunscreen do you use on your face & body? Do you sunbathe or use tanning beds? Do you burn easily in moderate sunlight? Do you have a tendency to redness? yes yes yes no no no

How many alcoholic beverages do you consume weekly? obvious dryness flakiness tightness

Do you blush easily when nervous? Do you suffer from sinus problems? occasionally Do you ever experience skin breakouts? yes yes yes no no no

yes yes yes

no no no occasionally

Do you ever experience oily shine during the day?

yes no

Do you drink more than 4 caffeinated beverages daily? (coffee,tea,soft drinks) Do you ever experience a burning, itching sensations on your skin? Have you ever experienced claustrophobia? What type of massage pressure do you prefer? (light, medium, or firm) If yes, please specify and inform us of any other known allergies female clients only Are you taking oral contraception? yes

no Are you currently having or due for your menstrual period? If yes, how many weeks?

yes

no

Are you pregnant or trying to become pregnant? male clients only What is your current shaving system? Do you experience irritation from shaving?

electric

wet shave yes no

Do you experience ingrown hairs? yes no 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. I understand that all treatments given are for general wellness purposes and that I should see a doctor or other appropriate health care provider for diagnosis and treatment of any suspected medical problems. Also, that it is my responsibility to keep my therapist informed of any changes in my health. Client Signature Date Witness Date This consultation card is to correctly evaluate your special skin care needs. This information is confidential and may be disclosed only to staff members, risk or quality improvement personnel to assess the quality of care and will not be passed on to a third party.

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