CONFIDENTIAL SKIN HEALTH QUESTIONNAIRE What is the reason for your visit? * Have you ever had a facial treatment before? * Yes No If yes, how was your previous experience? What are your expectations for this facial? * How have you'be been feeling recently? * Happy Content Sad/Depressed Confused Tbh, not sure What conditions are you trying to improve? * Dark Circles Acne Fine Lines/Wrinkles Scarring Dryness Clogged Pores Sensitivity/Redness Excess Oil Other How would you describe your skin? * Normal Combination Dry Oily Sensitive What does your current skincare regimen include? * Cleanser Toner Antioxidant Serum Eye Cream Spot Treatment Moisturizer Sunscreen Vitamin C Serum Face Oil Chemical Peel Any known allergies? * Yes No Please list all your known allergies In our treatment program, it may be necessary to recommend alterations or additions to your homecare regimen, would that be okay with you? * Yes No My facials are not regular facials. We do energy healing, is this something you're okay with? * Yes No Are you sensitive to fragrances? * Yes No If you selceted yes, please list the ones you dislike below May I record/take photos of your service for content? * Yes No How did you hear about my buisness? * Instagram Google Facebook Referral Other If referred by friend - Please enter their name so you can recieve a discount on todays service Thank you!
