Name		Date of Birth		ex. 01/08/69
Address
City		State		Zip
Phone		Email

What is your skin type? (Please check all that apply.)

Normal      Dry      Oily      Acne Prone      Combination in T-Zone

What skin conditions do you wish to treat? (check all that apply)

Acne      Age Management      Blackheads (comedones)      Elasticity

Hyperpigmentation      Rosacea      Texture      Whiteheads (milia)

What improvements would you like to see in your skin?

How satisfied are you with the results of your current skincare regimen?

Very Satisfied      It's OK      I need help      Don't EVEN look at me

What skincare products do you currently use on a regular basis?

Cleanser      Moisturizer      SPF

All Other

I don't follow a regular home skincare regimen.

Please check any treatments you have received in the last two years.

Chemical Peel      Laser Resurfacing      Microdermabrasion

Accutane      RetinA      Other

Please list ALL foods, drugs, products, etc. from which you have experienced allergic reactions.

Stress Level: High      Medium      Low           Smoker

Normal number of hours slept nightly

Number of alcoholic beverages consumed weekly

Digestive Problems (bloating, gas, stomach duress, acid reflux, etc.) Please describe

Hormone Therapy: Yes      No Describe

Prescribed Medications or Natural Supplements