Name:*

Address:

Phone:*

Email:*

Age:

Under 21
21-30
31-40
41-50
51-60
60+

Are you an existing client at the Escape Skincare Salon?

Yes
No

Within the last year, have you been under a physician's care?

Yes
No

Within the last year, have you been under a dermatologist's care?

Yes
No

Within the last nine months, have you undergone any surgery?

Yes   Specify:
No

Have you had any of these health problems in the past or present?

Cancer
Diabetes
Epilepsy
Heart problem
Hormone imbalance
Spinal injury
Hysterectomy
Thyroid condition
Varicose veins
Systemic disease

List medications, supplements, vitamins, diuretics, slimming tablets etc. that you take regularly:

Do you smoke?

Yes
No

Do you follow a restricted diet?

Yes
No

Do you have regular sleep patterns?

Yes
No

Do you wear contact lenses?

Yes
No

Do you have metal implants or a pacemaker?

Yes
No

With what temperature of water do you cleanse?

Cool
Warm
Hot

Do you have any special skin problems pertaining to your face or body?

Yes   Specify:
No

What skin care products are you currently using?

Soap
Cleanser
Toner
Moisturiser
Masque
Exfoliator
Eye products
Others

Have you ever had chemical peels, laser, microdermabrasion or any resurfacing treatments?

Yes
No

In the last month?

Yes
No

Do you use Accutane, Retin A, Renova or Adapalene?

Yes
No

In the last 3 months?

Yes
No

Do you use an acne medication?

Yes
No

In the last 6 months?

Yes   Specify:
No

Are you currently using any products that contain the following ingredients?

Glycolic acid
Lactic acid
Any exfoliating scrubs
Any hydroxy acid product
Vitamin A derivatives
      (i.e. retinol)

How much plain water do you consume daily?

How many alcoholic beverages do you consume weekly?

Do you ever experience these conditions on your skin?

Flakiness
Tightness
Obvious Dryness

What spf sunscreen do you use on your face?

What spf sunscreen do you use on your body?

Do you sunbathe and/or use tanning beds?

Yes
No

Do you burn easily in moderate sunlight?

Yes
No

Do you blush easily when nervous?

Yes
No

Do you have a tendency to redness?

Yes
No

Do you suffer from sinus problems?

Yes
No

Do you ever experience oily shine during the day?

Yes
No
Occasionally

Do you ever experience skin breakouts?

Yes
No
Occasionally

Do you drink caffeinated beverages?

Yes   Daily:
No

Do you ever experience a burning, itching sensation on your skin?

Yes
No

What is your pain threshold?

Low
Medium
High

Have you ever had a reaction to any of the following?

Cosmetics
Medicine
Iodine
Pollen
Food
Hydroxy acids
Animals
Fragrance
Sunscreens

Are you taking oral contraception?

Yes
No

Are you pregnant or trying to become pregnant?

Yes
No

Are you lactating?

Yes
No

What is your current shaving system?

Electric Shave
Wet Shave

Do you experience irritation from shaving?

Yes
No

Do you experience ingrown hairs?

Yes
No

To the best of my knowledge, I confirm that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment.^*

Clients name:*