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Tient nape <br /> last first <br /> client address <br /> e-mail address <br /> telephone: home ( ) work ( ) cell ( ) <br /> birthday under 2121-30 31-40 41-50 51-60 60+ <br /> month day <br /> how did you hear about me? <br /> your health <br /> 1 Within the last year, have you been under a physician's care? _yes_no <br /> 2 Within the last year, have you been under a dermatologist's care? _yes_no <br /> 3 Within the last nine months, have you undergone any surgery?_yes_no <br /> If yes, please specify <br /> 4 Have you had any of these health problems in the past or present? <br /> _cancer _diabetes _epilepsy_heart problem_hormone imbalance_spinal injury <br /> _hysterectomy_thyroid condition_varicose veins_systemic disease <br /> 5 List any medications, supplements, vitamins, diuretics, slimming tablets etc. that you take regularly? <br /> 6 Do you smoke? _yes_no <br /> 7 Do you exercise regularly? ___yes_no <br /> 8 Do you follow a restricted diet?_yes_no <br /> 9 Do you have regular sleep patterns?_yes_no <br /> 10 Do you wear contact lenses?_yes_no <br /> 11 Do you have metal implants or a pacemaker?--yes_no <br /> your skin <br /> 12 With what temperature of water do you cleanse?_cool_warm_hot <br /> 13 Do you have any special problems pertaining to your face or body?_yes_no <br /> If yes,please specify <br /> 14 What skin care products are you currently using? <br /> _soap_cleanser_toner_moisturizer_masque_exfoliator_eye products_others <br /> exfoliation history <br /> 15 Have you ever had any chemical peels, laser, microdermabrasion or any resurfacing treatments? <br /> _yes_no in the last month?_yes_no <br /> 16 Do you use Accutane, Retin A, Renova or Adapatane?_yes_no in the last 3 months?_yes_no <br /> 17 Do you use an acne medication?_yes_no in the last 6 months?_yes_no <br /> If yes,which drug? <br /> 18 Are you currently using any products that contain the following ingredients?_glycolic acid_lactic acid <br /> _any exfoliating scrubs_any hydroxy acid products_,vitamin A derivatives (i.e. retinol) <br /> moisture hydration <br /> 19 How much plain water do you consume daily? <br /> 20 How many alcoholic beverages do you consume daily? weekly? <br /> 21 Do you ever experience these conditions on your skin?_flakiness_tightness_obvious dryness <br /> 22 What spf sunscreen do you use on you face? body? <br /> 23 Do you sunbathe or use tanning beds?_yes_no <br /> capillary activity <br /> 24 Do you burn easily in moderate sunlight?_yes_no <br /> 25 Do you blush easily when nervous?_yes_no <br /> 26 Do you have a tendency to redness?_yes_no <br /> 27 Do you suffer from sinus problems?_des,no <br />