Name*
Address*
City*
State*
Zip*
Email*
Phone*
Age
Birthday
Ethnic Background
Area or problem of most concern on your face:
List any skin problems
Previous
Current
Describe present skin care program
AM
PM
Which of the following are symptoms of your skin type?
	Fine lines around eyes & mouth
	Crinkled when pinched together
	Blackheads
	Dull crinkled surface
	Localized blemishes
What area?	NA Cheeks Forehead Mouth Area Chin
	Dark Spots
	Skin feels loose when jaw is pinched
	Face dropped & sagging
	Large pores
	Deep creases--even when smoothed out
	Fine red lines
What area?	NA Nose Inner Cheeks Chin Forehead
	White bumps
	Shiny
	Feels greasy
	Flakey/where?
Where?	NA Cheeks Nose Forehead
	Rosy or ruddy look
Does your skin feel tight and dry, even uncomfortable with moisturizers?
YES
NO
How often are you exposed to sun at length?
	Daily Weekends Occasional Rare
Do you use sunscreens?
YES
NO
Are you pregnant?
YES
NO
Stress Level	1 (low) 2 3 4 5 6 7 8 9 10 (high)
Allergies to internal foods or medications:
Are you following a particular diet?
Do you use Lite Salt w/ potassium chloride
YES
NO
Do you smoke?
YES
NO
If yes, please enter amount per day
Alcohol intake per week?
Do you have any battery operated metal implants in your body?
YES
NO
List current conditions of muslces. Lightly pinch in horizontal direction.
Cheek	Soft Medium Firm
Neck	Soft Medium Firm
Upper Chest	Soft Medium Firm
Previous cosmetic facial improvement or surgery.
Facelift
Eyelift
Collegen/Fat injections
Laser
Electro-Therapy
Chemical Peel
Glycolic Peel
Dermabrasion
Have you ever had skin cancer?
YES
NO
Are you under a physicians care for any reason?
YES
NO
If yes, what kind(s) and for what?
Please check if you have or have ever had any of the following medical conditions.
Diabetes
High blood pressure
Warts
Dermal abrasions
Excessive moles
Vericose veins
Stomach ulcers
Poor circulation
Otherr skin conditions
Are you using/taking any of the following medications?
Acutane
High blood pressure medicine
Tetracyline (or any antibiotics for skin)
Thyroid medication
Glycolic acid
Retin-A (last 6 months)
Any AHA's