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Dermalogica Consultation Form

First Name:
Last Name:
*Your Email Address:
Do you currently have any medical conditions?:

Details of Current Medical Conditions:
List any medications, supplements, vitamins etc. that you take regularly:
Have you had any recent surgery ? (last 9 months):

Recent Surgery Details:
Do you smoke?:

Do you exercise regularly?:

Do you follow a restricted diet?:

Rate your level of stress:
Do you have any special skin problems pertaining to your face or body?:

Skin Problem Details:
What skin care products are you currently using on your Face (Select all that apply):

What skin care products are you currently using on your Body (Select all that apply):

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

Do you use Accutane, Retin-A, Renova, Adapalene or other prescription skin products?:

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

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?:

What SPF Sunscreen do you use on your face?:
What SPF Sunscreen do you use on your body?:
Do you sunbathe or use sunbeds?:

Do you burn easily in moderate sunlight?:

Do you blush easily when nervous?:

Do you have a tendency to redness?:

Do you suffer from sinus problems?:

Do you ever experience oily shine during the day?:

Do you ever experience skin breakouts?:

Do you drink more than 4 caffeinated beverages daily?:

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

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

(Females only) Are you pregnant or trying to become pregnant?:

(Males only) What is is your current shaving system?:

(Males only) Do you experience irritation from shaving?:

(Males only) Do you experience ingrown hairs?:

What are your skin care goals?:
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