SKIN ASSESSMENT

Consultation Form

CONFIDENTIAL HEALTH HISTORY

All information provided is voluntary. It will be kept confidential and secure. This information is used to determine contraindications to treatment, factors that can impact skin health and to provide customized home care regimen to restore skin health.

Health & Skin Concerns

Lifestyle

DIET How many days a week do you consume:
Processed Foods
Broiled/Grilled Foods
Baked Goods
Fruits
Vegetables
Vitamin D3
Fish Oil Supplement
Multivitamin

Fitzpatrick Skin Scale

Skin Care History: Cosmetics & Treatments Used

Future Appointments/Contact

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand withholding information or providing misinformation may result in adverse skin reactions from treatments or products received. I am aware that it is my responsibility to inform my skin therapist of my current medical or health conditions, and to update this history when necessary. I release Touch of Joy Skin Health and the skin therapist from liability and assume responsibility thereof.
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You may send a clear picture of yourself (Front, left side, and right side). Thank you.
Left side
Right side
Other area of concerns