Please answer the following questions so that your Skin Care Specialist may have a better understanding of your general health and lifestyle, thereby enabling your Skin Care Specialist to accurately analyze and asses your skin care needs.

Name *

First Name

Last Name

Email *

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthday *

YYYY

Phone *

(###)

###

####

What type of work do you do? *

Have you seen a dermatologist in the past year? *

If yes, list dermatologist's name, contact info and reason for visit

Are you currently under a physicians care? *

If yes, list dermatologist's name, contact info and reason for visit

Are you currently taking any medications? *

If yes, please list *

Please rate your stress level 1-5 (5 being the highest) *

Do you take nutritional supplements? *

Do you exercise? *

Do you have a tendency to scar? *

Do you have any allergies? *

Do you feel your skin is sensitive? *

Are you on hormone therapy? *

Are you currently taking birth control pills? *

Are you pregnant or nursing? *

Are you currently having skin care treatments? *

If yes, what type of treatments

Please check if you are presently using or have used in the past any of the following

Benzoyl Peroxide (BP)

Glycolic Acid (AHA)

Lactic Acid (AHA)

Resorcinol

Salicylic Acid (BHA)

Do you have or have you had any of the following the last 14 days?

Facial Cosmetic Surgery

Fillers

Light Treatment

Botox Injections

Laser Resurfacing

Collagen Injections

Microdermabrasion

What skin care products are you using at home?

List any prescription or antibiotic products

Do you use sunscreen? *

Have you had any direct sun exposure in the last 10 days? *

What skin conditions do you want to improve?

By clicking "Agree and consent to treatment" I have acknowledged that all the information provided by me is true and correct to the best of my knowledge.

I understand that some skin conditions may require more than one treatment and home care products to achieve the result desired. Results cannot be guaranteed due to individual skin type(s) and condition(s).

I understand I need to give consent to every treatment provided with ANY changes pertaining to the above questionnaire.

*

Agree and consent to treatment

Thank you! Your therapist will be with you shortly!

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MOD Skin and Body, 14130 Juanita Dr NE, Kirkland, WA, 98034, United States(425) 406-8455modskinandbodyclinic@gmail.com