Image Confidential Skin Health Questionaire

Patient/Client Information

Your information is kept confidential and handled as such. It will not be used for any purpose other than to address your skin care needs and advise skin treatments and/or products.

Name:

Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Email:

Medical Information

Date of Birth & Age:

Family Physician & Phone:

Do you smoke?

Yes No

How often?

Do you live with a smoker?

Yes No

Check any of the following you have been treated for:

Acne Depression Skin Disease High Blood Pressure Cold Sores Diabetes Cancer

List all allergies/allergic reactions to any product:

List all medications you are currently taking:

Check any of the following that apply to you:

Pregnant Trying to get pregnant On hormone therapy I get cold sores

Personal Information:

Check your current level of stress:

1 2 3 4 5 6 7 8 9 10

Check your normal level of stress:

1 2 3 4 5 6 7 8 9 10

Do you exercise & how often?

Do you use tanning beds?

Yes No

When you go out in the sun, do you (check only one):

Always burn Usually burn Sometimes burn Rarely burn Very Rarely Burn Never burn

Have you ever been under the treatment plan of a:

Dermatologist Plastic Surgeon Esthetician

What skin line are you currently using?

Do you wear an environmental protection cream daily?

Yes No

If not, why?

Check how you feel about the overall quality of your skin:

1 (bad) 2 3 4 5 6 7 8 9 10 (fantastic)

Your skin type is? (Please check only one box)

Normal Dry/Dehydrated Oily Acne/Acne Prone Rosacea

Check the box or boxes that you would like to see improved in your skin in the next 30 days:

Reduction of fine lines Reduction of oil/acne Reduction of redness Reduction of brown spots/Sun damage Acne scars diminished

For more information:
IY Spa/Individually Yours Too
128 N Oliver
Wichita, KS 67208 US
Email: customerserv@iyspa.com
(316) 683-7350
Fax: (316) 260-1104

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