Skin Care Questionnaire - Dr. Garth Fisher · List the brand names next to the products used. Brand...
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SkinCare What are your current skincare concerns? ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ What skin care treatments or procedures have you had in the past? ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ If you’ve had previous skin care treatments were you pleased with the outcome? Yes No (If no, why were you dissatisfied) ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Please circle 3 things you would like to improve about your skin. Lines Wrinkles Rough Texture Dull Pores Blotchiness Dry & Tight Age Spots Breakouts Oiliness Prevention Do you have sensitive skin, occasional or recurring skin problems we should be aware of? Yes No (If yes, please explain) ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Have you ever experienced allergic reaction to skin products? Yes No (If yes, please explain) ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Are you currently using any skin lightening products (e.g. Retin A or Hydroquinone)? Yes No (If yes, what products?) ___________________________________________________________________________________________________ List your current skincare routine. List the brand names next to the products used. Brand Name Cleanser(s) Yes No Exfoliation Yes No Serum/Hydration Yes No Toner Yes No Moisturizer Yes No SPF/Sunscreen Yes No Masks Yes No Eye Gel/Creams Yes No Retin-A or similar product Yes No 120 S. Spalding Drive, Suite 222, Beverly Hills, California 90212 Medical 310-273-5995 Biomed Spa 310-247-8111 Skin Care Questionnaire
Transcript of Skin Care Questionnaire - Dr. Garth Fisher · List the brand names next to the products used. Brand...
SkinCareWhat are your current skincare concerns?
______________________________________________________________________________________________________________________________________________________________________________________________________
What skin care treatments or procedures have you had in the past?
______________________________________________________________________________________________________________________________________________________________________________________________________
If you’ve had previous skin care treatments were you pleased with the outcome? �Yes �No (If no, why were you dissatisfied)
______________________________________________________________________________________________________________________________________________________________________________________________________
Please circle 3 things you would like to improve about your skin.
Lines Wrinkles Rough Texture Dull Pores Blotchiness Dry & Tight Age Spots Breakouts Oiliness Prevention
Do you have sensitive skin, occasional or recurring skin problems we should be aware of? �Yes �No (If yes, please explain)
______________________________________________________________________________________________________________________________________________________________________________________________________
Have you ever experienced allergic reaction to skin products? �Yes �No (If yes, please explain)
______________________________________________________________________________________________________________________________________________________________________________________________________
Are you currently using any skin lightening products (e.g. Retin A or Hydroquinone)? �Yes �No (If yes, what products?)
___________________________________________________________________________________________________
List your current skincare routine. List the brand names next to the products used.
Brand Name
Cleanser(s) �Yes �No
Exfoliation �Yes �No
Serum/Hydration �Yes �No
Toner �Yes �No
Moisturizer �Yes �No
SPF/Sunscreen �Yes �No
Masks �Yes �No
Eye Gel/Creams �Yes �No
Retin-A or similar product �Yes �No
120 S. Spalding Drive, Suite 222, Beverly Hills, California 90212 Medical 310-273-5995 Biomed Spa 310-247-8111
Skin Care Questionnaire
Anatomical Face Map
With respect to facial aesthetics, please mark those areas of the face that bother or trouble you. In the boxes provided please rate these areas on a scale of 1 to 5 (1 being least bothersome, 5 being most both-ersome). Feel free to draw on the chart to identify any other facial concerns.
120 S. Spalding Drive, Suite 222, Beverly Hills, California 90212 Medical 310-273-5995 Biomed Spa 310-247-8111
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