Anti-Aging Centers Skincare Consultation Card NAME: ______________________________________ DATE OF BIRTH: _____/_____/_____ ANTI AGING CENTERS OF CONNECTICUT ANTI-AGIN c of Connecticut YOUR HEALTH 1. Within the last year, have you been under a dermatologist’s or other physician’s care?
If yes, please specify: ______________________________________________________________________
2. Have you had any health problems in the past or present?
If yes, please specify: ______________________________________________________________________
3. List any medications, supplements, vitamins, diuretics, slimming pills, Isotretinoin, etc. that you take regularly: __________________________________________________________________________________________________ 4. Do you smoke? 5. Do you exercise regularly? 6. Do you follow a restricted diet? 7. Do you wear contact lenses? 8. Do you have metal implants, a pacemaker or body piercings? 9. Rate your level of stress on a scale of 1 to 5 (1 = low stress, 5 = high stress): ____________________________________ allergies?
If yes, please specify: ______________________________________________________________________
11. Do you sunbathe or use tanning beds? 12. Do you drink more than four caffeinated beverages daily (coffee, tea, soft drinks)? 13. Have you ever experienced claustrophobia? 14. Have you had any laser/IPL/radio frequency treatments or injectables in the past month?
If yes, please specify: _____________________________________________________________________
YOUR SKIN 1. What are your specific concerns/challenges with your skin? _________________________________________________ 2. What skincare products are you currently using?
FACE: [ ] soap [ ] cleanser [ ] toner [ ] moisturizer [ ] masque [ ] exfoliator [ ] eye products
3. Have you ever had chemical peels, microdermabrasion, or any resurfacing treatments? In the last month? 4. Do you use Retin-A, Renova, Adapalene or any other prescription skin products? In the last 3 months? 5. Are you currently using any products that contain the following ingredients?
[ ] glycolic acid [ ] lactic acid [ ] any exfoliating scrubs
[ ] any hydroxy acid product [ ] Vitamin A derivatives (i.e. Retinol)
6. Do you ever experience these conditions on your skin? [ ] flakiness [ ] tightness [ ] obvious dryness 7. What SPF sunscreen do you use on your face? _________________ Body? _________________ 8. Do you burn easily in moderate sunlight? 9. Do you have a tendency to redness? 10. Do you ever experience burning, itching or stinging sensations on your skin? FEMALE CLIENTS ONLY 1. Are you taking oral contraception? 2. Are you pregnant or trying to become pregnant? lactating? 4. Are you currently having or due for your menstrual period? MALE CLIENTS ONLY 1. Do you have any shaving challenges?
If yes, please specify: ___________________________________________________________________
QUESTIONS TO DISCUSS EVERY VISIT 1. Have you started any new medication since your last visit?
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
Client Signature: _________________________ Date: __________ Client Signature: _________________________ Date: __________
Client Signature: _________________________ Date: __________ Client Signature: _________________________ Date: __________
Client Signature: _________________________ Date: __________ Client Signature: _________________________ Date: __________
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Trip Date(s): 6 Months out Check that your passport has at least 6 months remaining on it from Get passport Your general doctor can do a travel appt. However, you can also check online for required shots and lifespans of shots. Hep A shot is a Check shots 3-part series. Must have 2 shots in the series to be covered. Work on packing list Send in application/deposit/copy of passport
GLOSSAIRES DES SIGLES Agent civil des services hospitaliers qualifié du service de santé desADMINISTRATION ET SOUTIEN DE L'HOMME (domaine deAssistance extérieure / Affaires étrangèresAttestation de formation complémentaire aux premiers secours avecAttestation de formation aux premiers secoursBureau conception des systèmes de force (EMAT/BCSF)Bureau d'édition et de diffusion de l'a
Anti-Aging Centers Skincare Consultation Card