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ARE YOU CURRENTLY UNDER THE CARE OF A DERMATOLOGIST OR A PHYSICIAN FOR YOUR SKIN? (IF YES, EXPLAIN) ____________________________________ ________________________________________________________________________NAME OF PHYSICIAN: __________________________________ HAVE YOU EVER SEEN A DERMATOLOGIST, OR OTHER PHYSICIAN FOR YOUR SKIN? (IF YES, EXPLAIN) _______________________________________________ ________________________________________________________________________NAME OF PHYSICIAN: __________________________________ WHAT SKIN CARE PRODUCTS DO YOU USE TO CLEANSE YOUR FACE? _______________________________________________________________________ WHAT SKIN CARE PRODUCTS DO YOU USE TO MOISTURIZE YOUR FACE? _____________________________________________________________________ AGGRESSIVE EXFOLIATION TREATMENT IN THE LAST 2 WEEKS? (EXPLAIN) _________________________________________________________ ALPHA-HYDROXY ACIDS DATE: _________________________ TOPICAL FLOUROURACIL PREPERATION (WHEN & WHAT AREA OF YOUR BODY): ____________________________________________________ OTHER (INCLUDE TOPICAL ANTIBIOTIC, OTC ACNE REMEDIES, ETC.): _____________________________________________________________ IF YES, WHAT IS THE DOSAGE AND FREQUENCY: ___________________________________ IF YES, LAST TAKEN ON: _____________________________________________________ HYPERSENSITIVITY AND SKIN FRAGILITY
HAVE YOU EVER HAD A SKIN ALLERGY OR SENSITIVITY (RASH, IRRITATION, PEELING, SWELLING, HIVES, ETC.) TO: OTHER (LATEX, ETC.)? _______________________ DO YOU HAVE ANY KNOWN SYSTEMIC ALLERGIES TO ANYTHING? (IF YES, PLEASE LIST) ___________________________________________________ _______________________________________________________________________________________________________________ DO YOU “FLUSH” OR “APPEAR REDDENED” EASILY WHEN YOU EAT SPICY FOOD, DRINK ALCOHOL, GET ANGRY, GO IN THE SUN, ETC.? 7 8 0 1 C e n t e r A v e n u e S u i t e 2 0 2 · H u n t i n g t o n B e a c h C A 9 2 6 4 7 · 7 1 4 . 2 3 0 . 2 4 4 0 · 7 1 4 . 2 3 0 . 2 4 4 1 f a x FREE RADICAL EXPOSURE
HOW OFTEN & TYPE: ____________________________________________ HOW MUCH? __________________________________________________ HOW MUCH? __________________________________________________ LIST ANY DIETARY CONCERNS: _____________________________________ EXPLAIN: _____________________________________________________ IF NOT HOW MUCH? ____________________________________________ TYPE OF VITAMINS: _____________________________________________ ANTIOXIDANTS: ____________________________________ OTHERS: _____________________________________________________ FOR WOMEN ONLY
DURING PREGNANCY DID YOU EVER EXPERIENCE HYPERPIGMENTATION OR A “PREGNANCY MASK”? PIGMENTATION (FITZPATRICK SCALE)
OTHER: ____________________________________________ WHAT IS YOUR NATIONALITY (HERITAGE)? _____________________________________________________________________________________ VASCULARITY
DO YOU HAVE ANY HISTORY OF ACNE OR PERIODIC BERAKOUT? DO YOU ONLY EXPERIENCE A BREAKOUT AROUND YOUR MENSTRUAL CYCLE? DO YOU ALWAYS HAVE A PIMPLE OR SOME TYPE OF BREAKOUT? FACIAL WRINKLES
7 8 0 1 C e n t e r A v e n u e S u i t e 2 0 2 · H u n t i n g t o n B e a c h C A 9 2 6 4 7 · 7 1 4 . 2 3 0 . 2 4 4 0 · 7 1 4 . 2 3 0 . 2 4 4 1 f a x SKIN TYPE
DOES YOUR SKIN EVER FLAKE OR FEEL TIGHT AND DRY? IS YOUR SKIN EVER SHINY A FEW HOURS AFTER CLEANSING? HOW OFTEN DO YOU EXPERIENCE BLACKHEADS OR BLEMISHES? ABILITY TO HEAL
DOES YOUR SKIN APPEAR FRAGILE OR BURN EASILY? IF YES, EXPLAIN: ______________________________ DO YOU HAVE ANY PROBLEMS HEALING FROM A CUT OR BURN? IF YES, EXPLAIN: ______________________________ DO YOU EVER USE DEPILATORIES OR WAXES ON YOUR FACE? IF YES, EXPLAIN: ______________________________ IF YES, EXPLAIN: ______________________________ SUN HISTORY & LIFESTYLE
OCCUPATION: ________________________________ HOBBIES: ___________________________________ IN THE PAST (INCLUDING CHILDHOOD) DID YOU LIVE IN A SUN BELT? WHERE DID YOU LIVE? __________________________ IN THE PAST HAVE YOU NEGLECTED TO USE A SUNSCREEN? IF YES, EXPLAIN: ______________________________ IF YES, WHEN? ________________________________ DO YOU CURRENTLY WEAR A SUN PROTECTION PRODUCT ALL DAY, EVERYDAY? ARE YOU WILLING TO WEAR A SUN PROTECTION PRODUCT ALL DAY, EVERYDAY? HAVE YOU OR ANY MEMBER OF YOUR FAMILY HAD SKIN CANCER? IF YES, WHO? _________________________________________ ANATOMICAL LOCATION: _________________________________________ ENVIRONMENTAL POLLUTION
HOW DO YOU WANT TO IMPROVE YOUR SKIN? _______________________________________________________________________________________ _____________________________________________________________________________________________________________________ WHAT SPECIFIC AREAS DO YOU WANT TO TREAT? SKIN CARE CONSENT: I understand that although the products used for facial and body treatments at Minuet Day
Spa is of the highest quality, it is possible that I may have an adverse reaction to a product or treatment. I understand that the risk of an adverse reaction is extremely low, however I accept the risk and consent to treatment by the thera-pists at Minuet Day Spa.
CLIENT SIGNATURE: ___________________________________________________________________________ DATE: _________________________
THERAPIST SIGNATURE: _______________________________________________________________________ DATE: _________________________
7 8 0 1 C e n t e r A v e n u e S u i t e 2 0 2 · H u n t i n g t o n B e a c h C A 9 2 6 4 7 · 7 1 4 . 2 3 0 . 2 4 4 0 · 7 1 4 . 2 3 0 . 2 4 4 1 f a x

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