MedSpa Patient Consultation Form
Step
1
of
5
20%
Personal Information
Name
(Required)
First
Last
Phone
(Required)
Email
DOB
MM slash DD slash YYYY
What is your gender?
(Required)
Female
Male
Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
How were you referred to us?
Facebook
Instagram
Google
Referral
Other
Are you employed?
Yes
No
What is your current occupation?
Does your job require that you work outdoors?
Yes
No
Your Skin Care
Have you ever had a facial treatment before?
Yes
No
When?
Have you ever had a body spa treatment before?
Yes
No
When and what treatment?
Which of the following best describes your skin type?
TYPE I: Fair skin tones - Always burns, never tans
TYPE II: Light skin tones - Burns easily, tans slightly
TYPE III: Fair to olive skin tones - Burns moderately, tans moderately
TYPE IV: Light brown skin tones - Burns slightly, tans easily
TYPE V: Dark brown skin tones - Rarely burns, tans easily
TYPE VI Dark brown to black skin tones - Never burns, tans easily
Do you have any special skin problems or concerns pertaining to your face or body?
Yes
No
Please specify
Have you ever had chemical peels, laser treatments, or microdermabrasion?
Yes
No
Has it been within the last month?
Yes
No
Do you use Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinal/Vitamin A derivative products?
Yes
No
Please specify what and when last used
Have you used acne medication?
Yes
No
Please specify what and when last used
Have you experienced Botox, Restylane, or collagen injections?
Yes
No
Please specify
What skin care products are you currently using?
Cleanser
Toner
Day Moisturizer
Night Moisturizer
Exfoliator
Mask
Eye Product
SPF/Sunscreen
Scrubs
Makeup Products
Soap
Shower Gels
Body Lotions
Self-tanning lotions/creams
Have you used any hair removal methods in the past six weeks?
Yes
No
Check all that apply
Shaving
Stringing
Waxing
Depilatories
Elecrolysis
Plucking
Tweezing
What areas of concern do you have regarding your Skin?
Breakouts/acne
Sun damage
Rosacea
Flaky skin
Sun/liver/brown spots
Uneven skin tone
Excessive oil/shine
Dull/dry skin
Redness/ruddiness
Blackheads/whiteheads
Wrinkles/fine lines
Broken Capillaries
Dehydrated
Other
What other concern for your skin?
What areas of concern do you have regarding your Eyes?
Dehydrated
Dark circles
Wrinkles
Puffiness
Other
What other concerns for your eyes?
What areas of concern do you have regarding your Lips?
Dehydrated
Cracked/chapped lips
Other
What other concerns for your lips?
Have you ever had an allergic reaction to any of the following (Check all that apply)
Cosmetics
Fragrance
Animals
Drugs
AHAs
Food
Latex
Iodine
Medication
Shellfish
Sunscreens
Pollen
Other
Please Specify
What SPF do you use on your face?
Have you had any recent tanning bed or sun exposure that changed the color of your skin?
Yes
No
Please specify
Lifestyle
How many glasses of water do you drink per day?
<1 glass
1-3 glasses
4-7 glasses
8+ glasses
How many caffeinated beverages (coffee, tea, soda, etc) do you consume per day?
None
1-2 drinks
3-5 drinks
4-7 drinks
8+ drinks
How many alcoholic beverages do you consume per week?
None
1-2 drinks
3-5 drinks
4-7 drinks
8+ drinks
How many hours of sleep do you get per night?
<3 hours
3-5 hours
6-8 hours
8-10 hours
10+ hours
Which foods do you consume on a regular basis?
Fruits
Vegetables
Dairy/cheese
Eggs
Poultry
Fish
Grains/bread
Processed sugar
Processed meats
What does your daily commute look like?
Car
Bike
Public Transport
Walk
I don't commute
How often do you travel on a plane?
Never
1-2 times per year
1-2 times per quarter
Every month
Every week
How many hours do you spend in front of a screen or digital device?
<3 hours
4-6 hours
7-9 hours
10-12 hours
12+ hours
Do you exercise on a regular basis?
Yes
No
Do you smoke cigarettes, vape, or consume other tabacco products?
Yes
No
What are your stress levels on a scale from 1 to 5 (1 = low stress, 5 = high stress)
1
2
3
4
5
Female Patients
Are you taking oral contraceptives?
Yes
No
Any recent changes to or from your contraceptive treatments?
Yes
No
Are you pregnant or trying to become pregnant?
Yes
No
Are you experiencing any menopausal symptoms?
Yes
No
Are you undergoing any hormone replacement therapy treatments
Yes
No
Male Patients
Do you experience irritation from shaving?
Yes
No
Do you experience ingrown hairs as a result of hair removal?
Yes
No
Consent
(Required)
Consent
(Required)
I've reviewed and truthfully filled out the questionnaire. This information serves as a complete disclosure, taking priority over any prior conversations. I understand that not being entirely truthful or withholding information could lead to problems like skin irritation during the treatments. I freely choose to receive these treatments and release this facility, along with its staff including technicians and estheticians, from any liability. I take full responsibility for the results.
Signature
(Required)
Phone
This field is for validation purposes and should be left unchanged.
