Facial intake form

Name: ____________________________________________________________Home Phone:_________________________
Address:__________________________________________________________ Work Phone:__________________________
City:_________________________________ ________ State:________ Zip:__________ Cell:_________________________
Occupation:________________________ Employer:______________ E-Mail Address: _______________________________
How did you find out about Hired Hands?:_____________________________________ D.O.B. _______________________
In case of emergency, please notify:_________________________________________ @ phone #______________________
May we add you to our mailing list? ____yes ____ no Have you received a professional facial before? ____yes _____ no
Your Health
1. Within the last year, have you been under a physician’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? If yes, please specify______________________________________________________________ 4. Do you have any known allergies? □yes □no □Aspirin or Salicylates □Milk □Apples □Citrus □Grapes □Ingredients in Skin Care Products □Fish, Marine or Iodine □Latex __Sulfur 5. Have you had any of these health problems in the past or present? □Cancer □Diabetes □Epilepsy □Heart problems □Hormone imbalance □Spinal injury □Hysterectomy □Thyroid condition □Varicose veins □Systemic disease □Cold sores □Claustrophobia □Hepatitis □High/low blood pressure □Autoimmune disorder □Stroke □Fainting □Asthma □Eating disorder 6. List any medications, supplements, vitamins, diuretics, slimming tablets, etc. that you take regularly _____________________________________________________________________________________________ 7. Do you have regular sleep patterns? □yes □no 10. Do you wear contact lens? □yes □no 8. Do you regularly exercise? □yes □no 11. Do you follow a restricted diet? □yes □no 9. Do you have metal implants or a pacemaker? □yes □no 12. Do you smoke? □yes □no Skin Care History
13. Have you ever had a chemical peel, laser, microdermabrasion or any resurfacing treatments? □yes □no in the last month? □yes □no 14. Do you use Accutane, Retin A, Renova, Adapalene, Triluma, Metrogel, or Tazarotene? □yes □no in the last 3 month? □yes □no 15. Do you use an acne medication? □yes □no in the last 6 month? □yes □no 16. Are you currently using any products that contain the following ingredients? □Glycolic Acid □Benzoyl Peroxide □Resorcinol □Salicylic Acid □Lactic Acid □Any exfoliating scrubs □Any hydroxy acid products (AHA or BHA) □Vitamin A derivatives 17. Do you have or have you had any of the following in the last 14 days? □Facial Cosmetic Surgery □Botox Injections □Collagen Injections □Fillers □Light Treatments 18. What Skin Care products are you currently using? _____________________________________________________________________________________________
Your Skin
19. Which of the following are you currently experiencing?
□Skin Cancer □Dermatitis □Keloid Scarring □Acne □Rosacea □Broken Capillaries □Treatment Reactions □Hypo-pigmentations □Hyper-pigmentation 20. What are conditions are you wanting to improve? □Acne/ Breakouts □Facial Scarring □ Hyper-pigmentation □ Hypo-pigmentations □Enlarged pores □yes □no 22. Do you use sun screen when outdoors? □yes □no
Female Clients Only
23. Are you taking oral contraceptives? □yes □no 25. Are you lactating? □yes □no 24. Are you pregnant or trying to become pregnant? □yes □no Male Clients Only
26. What is your current shaving system? □electric □wet shave 27. Do you experience irritation from shaving? □yes □no 28. Do you experience ingrown hairs? □yes □no Client or Parent Signature: ____________________________________________________ Date: __________________ Skin Care Therapist: _________________________________________________________ Date: __________________
I confirm (to the best of my knowledge) that the answers I have given are correct and that I have
not withheld any information that may be relevant to my treatment.

1.Client Signature: Date: ______ 2.Client Signature: ______________________ Date: ______
3.Client Signature: _____________________ Date: ______ 4.Client Signature: ______________________ Date: ______
5.Client Signature: _____________________ Date: ______ 6.Client Signature: ______________________ Date: ______
7.Client Signature: _____________________ Date: ______ 8.Client Signature: ______________________ Date: ______
9.Client Signature: _____________________ Date: ______10.Client Signature: ______________________ Date: ______
This consultation card is to correctly evaluate your special skin care needs. This information is
confidential and may be disclosed only to staff members, risk or quality personnel to assess the quality
of care and will not be passed on to a third party.

Source: http://www.hiredhandsdayspa.com/site/wp-content/uploads/facial-intake-form.pdf

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