Unique Skin Formulations Inc.
Informed Consultation Client History Form
Date of Consultation __________________
Please answer all questions to the best of your ability. It is mandatory to fill out this form completely before your
(Shaded area for office use only)
Type of Program________________
Phone Fax Cell
Client‟s guardian (if under 18yrs)
Client full name________________________________
City _________________________ State_____________ Zip____________
Phone_______________ Work____________ Cell______________
(Person, advertising, etc.)
Date of Birth____________________ How many children do you have? ______
For the following questions circle Yes or No. Your answers are for our records only and are strictly confidential. Please note that during your initial
visit, you will be asked some questions about your responses to this questionnaire, and there may be additional questions concerning your health.
Medical Health History
Have you ever been diagnosed, treated for or experienced any symptoms of the following conditions or diseases?
High or low blood pressure Yes____ No____ Sinus Problems Yes____ No____ Allergies Yes____ No____ Fatigue Yes___ No__ Dizziness Yes____ No____ Shortness of Breath Yes____ No____ Back Pain Yes____ No____ Spasm Yes____ No____ Swelling Yes____ No____ Numbness Yes____ No____ Paralysis Yes____ No____ Ulcers Yes____ No____ Indigestion Yes____ No____ Constipation Yes____ No____ Cold feet or hands Yes____ No____ Varicose Veins Yes____ No____ Stroke Yes____ No____ Damaged heart valves, including rheumatic heart disease Yes____ No____ Heart Murmur Yes____ No____ Arthritis or painful swollen joint Yes____ No____ Cardio Vascular disease Yes____ No____ Heart trouble heart attack, angina,( chest pain) coronary insufficiency Yes____ No____ HIV/AIDS Yes____ No____ Cancer Yes____ No____ Diabetes Yes____ No____ Herpes Yes____ No____ Persistent swollen glands Yes____ No____ Problems with mental health Yes____ No____ Respiratory Problems or emphysema bronchitis Yes____ No____ Hepatitis Jaundice or liver disease Yes____ No____ Hormone Imbalance or Thyroid Problems Yes____ No____ Asthma or have fever Yes____ No____ Epilepsy Yes____ No____ Claustrophobia Yes____ No____ Uterine Fibroids Yes____ No____ Conjunctivitis (pink eye) Yes____ No____ Seborrhea Yes____ No____ Eczema Yes____ No____ Fainting Spells or Seizures Yes____ No____ Psoriasis Yes____ No____ Fever Blisters/Cold Sores Yes____ No____ Thyroid Problems Yes____ No____ Kidney Trouble Yes____ No____ Are you currently under a Dermatologist care if yes give Dr„s name address phone number___________________________________________________________ If you suffer from fever blisters, cold sores or oral herpes, how many times a year do you break out?_____________ Are you wearing contact lenses? Yes____ No____ Have you had any serious trouble associated with any previous dental work and are you wearing removable dental appliances? __________________________________ Are you allergic to latex? If yes give symptoms_______________________________________ Are you allergic or have you had a reaction to ( please circle )- local antibiotics, penicillin or other antibiotics, sulfur drugs, barbiturates or sleeping pills, aspirin, Iodine, codeine, other ___________ Have you ever had any treatment for a tumor or growth? Yes____No____ Do you have any metal implants? Yes____ No____ Do you have a Cardiac pace maker? Yes____ No____ Do you suffer form anemia or hyper acidity Yes____ No____ Have you had any serious illness or surgeries, or been hospitalized in the past five years? If yes give dates________________________________________________________ Are you basically in good health? Yes____No____ Has there been change in your general health within the past year? Yes____ No____ Your last physical examination was on___________________________________ The name and address of your physician is ___________________________________________________________________________ Have you had any plastic surgery done before? Yes_____ No_____ If yes give dates name, address, phone number of the surgeon? Do you have any disease, condition or problem not listed that you think we should know about? Yes____ No_____ if yes please explain_____________________________ Are you taking any medication(s) including non-prescription medicine? Yes____ No____ If yes please list__________________________________________________
Facial Skin Conditions
Please circle any skin conditions YOU FEEL may apply to your skin.
Dryness Oiliness Itching Large pores Clogged Pores Redness Sensitivity Rashes Allergies Superficial Lines Deep Lines Wrinkles Blackheads White heads Acne Sun damage Poor Elasticity Poor Circulation Discoloration Scarring Stretch Marks Cysts Dark/Brown Spots Blotchy Skin Do you suffer from acne or scalp problems? Yes____ No____ If yes what age did your skin or scalp problem begin? _____________________________________________________________ Yes____ No____ Are there any acne or scalp problems in the family such as ( please circle Parents, Siblings) or other family members?___________________ Do you have any flaking / sensitivity: in brows Yes____ No____ inner cheeks Yes____ No____ on hair line Yes____ No____ sides of nose Yes____ No____ between brows?
Have you experienced any of the following challenges in connection with your skin? (Please circle) Acne on face chest or back Acne Keloidalis- ( inflamed infected acne bumps on scalp or back of neck associated with unsanitary barber clippers) Rosacea Fine Lines Wrinkles Age Spots on Hands Hyper-pigmentation Hypo-pigmentation ( loss of pigment white spots) Moles Distended Capillaries Warts Ingrown Hairs Dry Scalp Dehydration Cellulite Thinning Hair Have you ever visited a Clinical Esthetician before? Yes____ No____ If yes how often__________ Did the treatments meet your expectations? Yes____ No____ Do you pick your skin? Yes____ No____ How do you feel about your skin/appearance? Is there a specific reason why you came to see us? Exactly what results do you hope to obtain? Please list any products or ingredients that have caused you skin to be sensitive_______________________________________________
FEMALES Do you have a normal menstrual cycle? Yes____ No____ Are you pregnant? If yes when is your due date? _____________________ Are you taking Birth Control Pills or any prescription birth control methods? Yes____ No____ If so please list___________________________________________ Do you suffer from PMS? Yes____ No____ Have you or are you experiencing menopause? Yes____ No____
LIFE STYLE HABITS Do you take vitamin or mineral supplements? If so please list them_______________________________________________________ What is your daily stress level (please circle) Light Medium Heavy How do you prepare your food? (please circle) Steamed Boiled Baked Stir Fried Do you consume a lot of dairy products including cheese products? Yes____ No____ Do you eat a lot of red meat? Yes____ No____ Do you eat much junk food? Yes____No____ Do you smoke? Yes____ No_____ If yes how many cigarettes a day? Yes____ No____ Do you drink alcohol? If so how many drinks a day? Do you feel your dietary habits are: Healthy Moderate Poor (please circle) Are you a coffee or tea drinker? Yes____ No____ If so decaf or regular? How many cups a day? Do you exercise? Yes____No____ Do you exercise strenuously? Yes____ No____ Do you shower afterward? Yes____ No____ List your summer sports____________ winter sports____________
SKIN CARE TREATMENTS
Have you had any of the following treatments? Micro dermabrasion Yes____ No_____ Bust treatments Yes____ No____ Skin Peels Yes____ No____ Reflexology Yes____ No____ Laser skin rejuvenation Yes ____No____ Laser hair removal Yes____ No_____ Body massage Yes____ No____ Edermologie ( cellulite treatments) LED Light treatments Yes____ No_____ Facials Yes____ No____ Waxing Yes____ No____ Back Facials Yes____ No ____ Which of the following above treatments are you interested in? ________________________________________________________________________________________ Have you every used retin A or retinol? Yes ____ No ____ If yes give date last used___________________________ Have you ever used glycolic or AHA? Yes___ No___ If yes give date last used________________________ Have you ever used Accutane Yes____ No____ If yes give date last used________________ Have you ever used Benzoyl Peroxide (BPO) Yes____ No ____ All over or just in spots? Yes____ No____ If yes give date last used___________________ and did you ever have an allergic reaction such as severe itching, rash, fine bumps, or swollen eyes (circle one) Have you ever had an allergic reaction or stinging using Aloe Vera? Yes____ No ____ Have you ever had an allergic reaction to bleach or fade creams, lotions, or gels, resulting in swelling extreme itching redness or fine bumps? Yes____ No____
Do you burn easily? Yes____ No____ Do you sun bathe? Yes____ No____ If yes how long do you stay out in the sun? _______________ Do you use sunscreen when you go out in the sun? Yes_____ No____ If yes what brand? ___________________ Do you use a cream lotion or gel? (circle one) Which SPF (i.e. 8, 15, 20, etc) _________
PRODUCTS YOU ARE CURRENTLY USING (fill in completely and list their brand names)
Cleanser _________________________ Toner ______________________ Moisturizer ________________________ Serum _______________________ Sunscreen________________________ Mask_______________________ eye care ________________________ Foundation______________________ Powder____________________ Cover –up______________________ Blush______________________ Hair Products___________________________ Hair Spray____________________ Oil sheen/ Braid spray_____________________ Hair Grease_________________ Hair Gel________________________
Do you suffer from razor bumps? (PFB) Yes____ No____ If yes where? _________________ Do you suffer from itching or irritation as a result of having razor bumps? Yes ____ No____ Do you have shadowing in the beard area? Yes____ No ____What do you use to shave with? (i.e. razor etc.) ___________________ Which direction do you shave? Upward downward or both please circle. How often do you use a blade? ______________________ What are the side effects if any? ___________________ What shaving products do you use on your skin to shave? _______________________________________________________ Do you wish to shave? Yes____ No ____
PLEASE READ CAREFULLY
All consultations are $55.00 fee and applicable toward Medical Esthetic Treatments only if purchased the day of your consultation. If no treatment program is purchased the fee for the consultation is $55.00 which includes photos taken for “before & after”, an informed consultation client history form which includes questions about the client‟s nutritional life style habits, skin condition, medical history, current product and medication use. An optional- e- Anti- Aging test given to determine your true physical age at the cellular level. The skin is analyzed to determine a treatment program and to recommend a proper skin care protocol you will need for home use. Color cosmetic testing is available which is also optional. All clients must fill out and sign informed consent forms for all treatment programs no exceptions. All payments are due in full at the time of each appointment. We are not currently set-up for monthly billing to offer payment plans at this time. We do not accept post dated checks for services, or products that are picked up. We accept checks, postal money orders, and credit/check cards for mail orders- DO NOT SEND CASH FOR MAIL ORDERS. All samples or products that are purchased must be picked up at the clinic or shipped to you only – no exceptions.
Please be considerate of others. Hours are by appointment only; all clients arriving more than 10 minutes later than your scheduled appointment must wait until all on time scheduled appointments are seen. All clients who reschedule for arriving late must pre-pay for their next appointment in full to reserve you space. Please give a 24 hour cancellation notice to avoid a 50% cancellation fee. We reserve the right to charge full payment for no shows. We respectfully ask that you do not bring any children who are not being rendered a service to the clinic, for your comfort and their safety; as it is difficult for small children to sit quietly, and we are also unequipped to accommodate clients with infants. You must agree to find child care for every appointment you make for a clinical service. If you bring any child who is not being rendered a service, your appointment will be forfeited and you must pre-pay for your next appointment in advance to reserve your space which is non- refundable. This is so that we can fulfill our commitment to give you and others the very best service. We thank you for your full cooperation and appreciate your business. I certify the information in my client profile above is true complete and accurate. I will not hold Unique Skin Formulations Inc. or its staff members responsible for any adverse reactions due to inaccurate information on my part. We reserve the right to terminate any business relationship with any client who is non-compliant to all policies, rules and regulations or who is willfully non-compliant with skin care protocols. I have read the rules and regulations outlined in this informed consultation form and agree to cooperate with its standards. Print Name________________________________ Client Signature ___________________________________ Date _______________________ Unique Skin Formulations Inc. 516 616-9142 office -e-mail lisa@ uniqueskinformulations.com- website www.uniqueskinformulations.com