BEST VIEWED ON A DESKTOP OR LAPTOP COMPUTER FOR OFFICE USE ONLYDate Consultant Referral CLIENT INFORMATIONFull Name * Date of Birth * Address *Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepaNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabweCountry Phone * Email * Gender *MaleFemale LIFESTYLEWork (check all that apply) StressfulHazardousPhysicalSedentary Leisure (check all that apply) OutdoorsSportsSedentaryPartierRisky / Thrill-seeker NUTRITIONTime of main meal of day Number of take-out meals per week How many meals a day? Portion sizes? A brief summary of your daily meal habits. If you need to explain differences between weekly and weekend habits please do so. Type of food groups eaten per week Food groups are: bread/cereal/rice/pasta, fruits, vegetables, meat/poultry/beans/nuts/fish, milk/yogurt/cheese, fats/oils/sweets Do you eat a fat-free diet? If yes, for how long? Any food intolerances? Any food allergies? Do you have Diabetes? YesNo Fluid intake (type and amount) Any recent weight fluctuation? Any vitamin supplements taken (quantity and how often) SUN EXPOSURE & GENETIC HISTORYTanning ability MC1R Gene (redhead)? Maternal/paternal genetic history (in regards to sun exposure issues) Location of birth and first 25 years Sunburn history Tanning bed history MEDICAL HISTORY & MEDICATIONMajor illness(es) YesNo Major surgery or surgeries YesNo Cosmetic surgery YesNo Cosmetic surgical implants YesNo Blood pressure medication YesNo Cardiovascular medication YesNo Vericose veins/bruising YesNo Hemophiliac/bleeding/clotting YesNo Impaired lymphatic system YesNo Skin bruising/marking YesNo Hepatitis YesNo Immune disorders YesNo Epilepsy/medication YesNo Thyroid disorders YesNo Keloid scarring YesNo Lupus/medication YesNo Rosacea/medication YesNo Asthma/medication YesNo Eczema/medication YesNo Dermititis/medication YesNo Psoriasis/medication YesNo Arthritis/medication YesNo Allergies/medication YesNo Epi pen carried YesNo Anti-depressants YesNo Acne/medication YesNo Antibiotics/antifungal medications YesNo GENERAL HEALTHHysterectomy YesNo Menopausal/medication YesNo Irregular menstruation YesNo Poly-cystic ovaries YesNo Endometiosis YesNo Superfluous hair problem YesNo Osteoporosis YesNo Poor sleep pattern/medication YesNo Pain/medication YesNo Stress/medication YesNo Cigarette smoker YesNo How many cigarettes per day? GENERAL SKIN CARECurrent feeling about skin (1-10, 10 being the best) 12345678910 Reason for appointment Previous skincare products used (past 5 years) Reason for discontinuing any specific product(s) Previous clinical services and frequency Were expectations previously met? YesNo CURRENT SKINCARE PRODUCTS & REGIMENCLEANSER Brand Application technique Type of skin labeled for TONER Brand Application technique Type of skin labeled for MOISTURIZER Brand Application technique Type of skin labeled for NIGHT CREAM Brand Application technique Type of skin labeled for EYE CREAM Brand Application technique Type of skin labeled for EXFOLIANTS Brand Application technique Type of skin labeled for MASKS Brand Application technique Type of skin labeled for SUN PROTECTION Brand Application technique Type of skin labeled for MAKEUP Brand Application technique Type of skin labeled for DECLARATIONThe information I have given above is true and correct to the best of my knowledge.Please type your full name to confirm. * VERIFICATIONPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank
