Client Questionnaire - B-Unique Beauty

Please fill out this form before your first appointment.

Name *

First

Last

Age *

DOB *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Cell Phone *

Email *

Ethnicity *

Medications: Antibiotics *

When and how long?

Accutane *

When and how long?

Benzoyl Peroxide *

When and how long?

Retin A Gel *

When and how long?

Retin A Cream *

When and how long?

Tazorac *

When and how long?

Differin *

When and how long?

Azalex *

When and how long?

Avita *

When and how long?

Cleocin-T *

When and how long?

E-mycin-T *

When and how long?

Copaxone *

When and how long?

Corticosteroids *

When and how long?

Quinine *

When and how long?

Androstendione *

When and how long?

Testosterone *

When and how long?

Progesterone *

When and how long?

Thyroid *

When and how long?

Gonadotrophin *

When and how long?

Danzol *

When and how long?

Cyclosporin *

When and how long?

Lithium *

When and how long?

Isoniazid *

When and how long?

Immuran *

When and how long?

Disulfuram *

When and how long?

Dilantin/Tegretol *

When and how long?

Steroids *

When and how long?

Marijuana *

When and how long?

Cocaine/Speed *

When and how long?

Other Meds

Your primary care physician: *

Phone *

Are you under a dermatologist's or other skin physician's care? *

If yes, doctor's name:

Lifestyle Considerations: Have you ever had any reaction to any products or anything you have put on your face? *

If yes, what products?

Please check any of these you are allergic to:

Sulfur
Aspirin
Latex

List any other allergies you know of:

Do you smoke? *

Do you use fabric softener or fabric softener sheets in the dryer? *

Do you swim in a chlorinated pool? *

Do you work around chemicals, tars, oils, grease, or inks? *

Occupation: *

Do you work nights? *

Are you currently under a lot of stress? (Common stress = job loss, new job, wedding, romantic breakup, death in the family or close friend, graduation, difficult home life, long commute, heavily scheduled). *

Women: Do you use birth control pills, shots, or use an IUD?

If so which one do you use?

What brand of pill?

Are you pregnant or nursing?

Men: Do you have shaving irritation?

What do you use for shaving?

Diet. Do you consume the following? Fast food *

How often per week?

Processed food *

How often per week?

Salty snacks *

How often per week?

Milk/Yogurt *

How often per week?

Cheese *

How often per week?

Whey or Soy protein *

How often per week?

Peanut butter *

How often per week?

Peanuts *

How often per week?

Sushi *

How often per week?

Kelp and Seaweed *

How often per week?

Miso soup *

How often per week?

Soy *

How often per week?

Vitamins *

How often per week?

Seafood *

Products Currently Using. (Please provide product names). Cleanser:

Toner

Serums

Moisturizers

Sunscreen

Mask

Foundation

Blush

Exfoliant (acid or scrubs)

Acne medications

Anything else?

Other Treatments. Have you done any of these for your skin in the last 90 days? Glycolic/Lactic/Mandelic Peels: *

When and where?

Any other chemical peel? If so, what kind?

When and where?

Microdermabrasion *

When and where?

Dermabrasion *

When and where?

Laser hair removal *

When and where?

Laser rejuvenation/resurfacing *

When and where?

Skin cancer removal *

When and where?

Facial waxing *

When and where?

Electrolysis *

When and where?

Other

How did you hear about us? *

Phone

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