Intake forms

Thank you for choosing to trust Skin Sense with your skin.
Please answer the following questions so that our Estheticians may have a better understanding of your general health and lifestyle, enabling us to accurately analyze and access your unique skin care needs.
What type of work do you do?Have you seen a Dermatologist in the past year? If yes, list Dermatologist’s name, contact information and reason for visit: Are you currently taking any medications? What is your genetic background? (This is for skincare analysis only) Please circle the following conditions you have/had experienced:hypertension Do you take nutritional supplements? Allergies:
Have you ever had an allergic reaction to any of the following:
Aspirin or Salicylates

If checked yes to any of the above, please explain Please list any other known allergiesHave you ever had Herpes Simplex? If yes, have you ever been treated with Denavir (Penciclovir), Zovirax (Acylivor) or Abreva?Are you being treated for Hepatitis? Yes Female clients only:Are you on hormone replacement therapy? Yes Are you presently taking birth control pills? Are you currently having skin treatments? If yes, what type of treatment(s)?Please circle if you are presently experiencing or have experienced in the past:Skin Cancer Please circle if you have or have you had any of the following in the last 14 days:Facial Cosmetic Surgery Hair Treatments (perm, color, etc.) Home Care:
Please circle the skincare products are you currently using at home:

Please circle if you are using or have used any of the following:Benzoyl Peroxide (BP) Glycolic Acid (AHA) Hydrocortisone (HC) Hydroquinone (HQ) Please circle if you have been prescribed the following products: Tretinoin (Retin A, Retin-A Micro , Renova, Avita) Azelaic Acid (Azelex , Finacea TM) Sun Protection:
Do you use a sunscreen?

What level of protection?Do you sunbathe or participate in outdoor activities? Yes Have you tanned in a tanning booth in the last 14 days? Have you had any direct sun exposure in the last 10 days? When exposed to the sun do you (Please circle one)Always burn, never tan Do you feel your skin is sensitive? What skin conditions do you want to improve? (Please circle all that apply)Acne and/or breakouts Hyperpigmentation (freckles, age spots) Is there any other necessary information your skincare specialists should know before beginning your treatment? If so, please explain: I have acknowledged that all the information provided by me is true and correct to the best of my knowledge. I also understand that some skin conditions may require more than one treatment and home care products to achieve the result desired. I hereby release Skin Sense from any liability pertaining to treatments, understanding thatresults cannot be guaranteed due to individual skin type(s) and condition(s).



2011_19_GI_magnomed.qxp 18.10.2011 09:33 Seite 1Gebrauchsinformation vor Anwendung aufmerksam lesen. magnomed® Magnes Diätetisches Lebensmittel für besondere medizinische Zwecke. Ergänzend bilanzierte Diät mit Süßungsmitteln. Liebe Leserin, lieber Leser! magnomed® wurde speziell zur diätetischen Behandlung von neuromus- kulären Störungen, z. B. von Muskel- und Wadenkrämpfen

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