COMPLIANCE INFO_TERI EISERT - Laserfiche WebLink

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oil secretion 28 Do you ever experience oily shine during the day?_yes_no_occasionally 29 Do you ever experience 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 you pain threshold?_low_medium_high 33 Have you ever experienced claustrophobia?_yes_no 34 What type of 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 reale 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 you 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 your skin care goals? 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 might be relevant to my treatment. client signature date client signature date client signature date client signature date client signature date client signature date client signature date client signature date client signature date client signature date client signature date client signature date client signature date client signature date client signature date client signature date client signature date client signature date March 2004