Dermalogica Consultation Form

Please complete the following consultation card.

Once we receive your information it will enable us to correctly evaluate your special skin care needs.

Just simply complete and submit and we will contact you

your details
full name
client address
post/zip code
telephone (home)
telephone (work)
under 21 21-30 31-40 41-50 51-60 60+
how did you hear about us?
your health
1 Within the last year, have you been under a doctor’s care? yes no  
2 Within the last year, have you been under a dermatologist’s care? yes no  
3 Within the last nine months, have you undergone any surgery? yes no  
  If yes, please specify
4 Have you had any of these health problems in the past or present?
cancer  epilepsy  heart problem  hormone imbalance  spinal injury 
hysterectomy  thyroid condition  varicose veins  systemic disease   
5 List any medications, supplements, vitamins, diuretics, slimming tablets etc. that you take regularly
6 Do you smoke? yes no  
7 Do you exercise regularly? yes no  
8 Do you follow a restricted diet? yes no  
9 Do you have regular sleep patterns? yes no  
10 Do you wear contact lenses? yes no  
11 Do you have metal implants or a pacemaker? yes no  
your skin
12 With what temperature of water do you cleanse? cool  warm  hot 
13 Do you have any special skin problems with your face or body? yes no  
If yes, please specify
14 What skin care products are you currently using?
soap  cleanser  toner  moisturizer  masque 
exfoliator  eye products  others 
exfoliation history
15 Have you ever had chemical peels, laser, microdermabrasion or any resurfacing treatments?
  yes  no 
in the last month? yes  no 
16 Do you use Accutane, Retin A, Renova or Adapalene? yes  no 
last 3 months? yes  no 
17 Do you use an Acne medication? yes  no 
last 6 months? yes  no 
If yes, which drug?
18 Are you currently using any products that contain the following ingredients?
  glycolic acid  lactic acid  exfoliating scrubs  hydroxy acid products  vitamin A derivatives 
moisture hydration
19 How much plain water do you consume daily?
20 How many alcoholic beverages do you consume weekly?
21 Do you ever experience these conditions on your skin? flakiness  tightness  obvious dryness 
22 What spf sunscreen do you use on your face?  
23 Do you sunbathe or use tanning beds? yes no  
capillary activity
24 Do you burn easily in moderate sunlight? yes no  
25 Do you blush easily when nervous? yes no  
26 Do you have a tendency to redness? yes no  
27 Do you suffer from sinus problems? yes no  
oil secretion
28 Do you ever experience oily shine during the day? yes  no  occasionally 
29 Do you ever eperience skin breakouts? yes  no  occasionally 
nerve activity
30 Do you drink caffeinated beverages (coffee, tea, soft drinks)? yes no  
How many daily?  
31 Do you ever experience a burning, itching sensation on your skin? yes no  
32 What is your pain threshold? low  medium  high 
33 Have you ever experienced claustrophobia? yes no  
34 What type of massage pressure do you prefer? soft  medium  firm 
35 Have you ever had a reaction to any of the following?
cosmetics  medicine  iodine  pollen  food  hydroxy acids  animals 
fragrance  sunscreens  other 
female clients only
36 Are you taking oral contraception? yes no  
37 Are you pregnant or trying to become pregnant? yes no  
38 Are you lactating? yes no  
male clients only
39 What is your current shaving system? electric wet shave  
40 Do you experience irritation from shaving? yes no  
41 Do you experience ingrown hairs? yes no  
questions to discuss every visit
42 Are you currently having or due for your menstrual period? yes no  
43 Have you started any new medication? yes no  
44 Have you had any recent dental x-rays? yes no  
45 What are you skin care goals?
This information is confidential and may be disclosed only to staff members, risk or quality improvement personnel to assess the quality of care and will not be passed on to a third party.