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 town/city county/state post/zip code email telephone (home) telephone (work) birthday 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? body? 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.