Microneedling Medical History Intake

Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Email
Are you currently using or taking (check all that apply):
- Isotretinoin/Accutane in the past 6 months
- Glycolic Acids
- Smoker
- Retina-A / Renova
- Any acne medications or Vitamin A derivatives
- Antibiotics in the past 2 weeks
- Contraceptives
- Retinols in skin care
- Hormone Replacement
HEALTH INFORMATION (check all that apply):
- Diabetes
- Asthma
- Heart problems
- Seizures
- Eczema
- Pacemaker
- Currently pregnant
- Psoriasis
- Metal implants
- Nursing
- Rosacea
- Cancer Treatments
- Cold Sores / Fever Blisters
- Scarring
- Staph / MRSA
- Herpes Virus
- Contact Lenses
- Epilepsy
- Auto-immine Disorders
- Claustrophobia
Are you under the care of a physician or Dermatologist?
- Yes
- No
List any medications, supplements, vitamins, herbs, diuretics that you take regularly:
Do you have allergies or sensitivities to (check all that apply):
- Aspirin/Salicylates
- Nuts
- Apples/Citrus/Grapes
- Milk / Dairy
- Apples/Citrus/Grapes
- Sulfur
- Latex
- Medicaitons
- Fragrances
- Skin Care
- Sulfur
- Latex
- Medications
- Cosmetics
- Fragances
- Skin Care Ingredients
Have you received Botox/Dysport or fillers such as Juvederm/Restylane treatments in the last 14 days?
- Yes
- No
Have you had any surgery, including cosmetic, in the past year?
- Yes
- No
Have you received a chemical peel, microdermabrasion, IPL, laser or other resurfacing treatment in the past month?
- Yes
- No
How often are you exposed to the sun, wether during work or at play?:
How often do you wear sunblock?
Have you had a facial before?
- Yes
- No
Do you prefer extractions when you have a professional facial? (check one):
- YES, my skin needs a lot of extractions
- YES, but only if my skin needs it
- NO, I prefer not to have extractions
What is your skin tone?
- Very Fair
- Medium
- Dark
- Medium Olive
- Very Dark
What do you believe best describes your skin type? (check all that apply):
- Normal / Combination
- Oily
- Sensitive
- Aging
- Acne
- Severe Acne
What are your skin concerns? (check all that apply):
- Acne /Breakouts
- Redness/Sensitivity
- Hyperpigmentation (brown spots, age spots)
- Blackheads/ Clogged Pores
- Rosacea
- Fine Lines/Wrinkles
- Sun Damage
- Uneven Skin Tone
- Age Prevention/Healthy Skin
- Under Eye Puffy/Dark Circles
- Excessively Oily
- Excessively Dry /Dehydrated
When it comes to caring for your skin at home, which statement best describes you? (check one):
- I barely use anything on my skin
- I use a cleanser and moisturizer
- I use cleanser, toner and moisturizer and occasionally will add in an extra product or two (For example - mask, serum, scrub , peel or eye cream)
- I use a full routine, complete with serums, masks and eye cream
READ AND INITIAL BELOW:
- Please note: A facial may cause the skin to purge resulting in a break out. This is normal and does not mean you are having a reaction to the products. If you experience any itching, burning, or rash following your facial treatment please notify your skin care professional immediately so they may advise you or find a different product for your skin.
- I am aware that certain medications and over-the-counter products can significantly increase the risk of injury when combined with skin care services.
- I understand I may carry Herpes and/or Staph/MRSA without any physical symptoms or a medical diagnosis. I also understand that the facial service does not allow the opportunity to contract these conditions from my technician.
- I understand all of the above mentioned reactions. I also understand if I change my skin care routine or medications, or my health condition changes, I must inform the professional PRIOR to any service in the future.
- I understand that there are often inherent risks associated with skin care services, and I agree that as a condition of providing these services on an ongoing basis, I will not hold Bee Waxed Cosmetics or the technician provider liable.
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Microneedling Medical History Intake

MICRONEEDLING CLIENT MEDICAL HISTORY INTAKE

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