consultation intake form

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

What is your primary acne concern(s)? *

Select all that apply.

Blackheads

Cysts

Dark Spots

Dehydrated Skin

Dry, Flaky Skin

Oily Skin

Pimples/Pustules

Razor Bumps

Sensitive skin

Shaving Irritation

Whiteheads

Which of the following describes your skin type? *

Select all that apply.

Dry

Normal

Oily

Combination (Oily/Dry)

Sensitive

Are you currently under the care of a dermatologist? *

Yes

No

Conditions you have had in the past two years: *

Select all that apply.

Anemia

Birth Control Pill

Cancer

Depo Provera Shots

Diabetes

Eczema

Epilepsy

HIV Positive or AIDS

Hearing Devices

Hemophilia

Hepatitis

Herpes Simplex/Sold Sore

High Blood Pressure

Hormone Problems

Hysterectomy/Ovary(ies) Removed

Nursing (currently)

PCOS

Pace Maker

Pregnancy

Psoriasis

Recent Surgery

Staph Infection

Thrombosis/Blood Clots/Strokes

Thyroid Problems

None

Prescribed and over-the-counter medications (past and present use): *

Select all that apply.

Accutane

Androstendione

Antibiotics

Antidepressants

Azelex

Benzoyl Peroxide

Cleocin-T

Cortisone

Cyclosporin

Danzol

Differin

Dilantin

Disulfuram

E-mycin-T

Gonadotrophin

Immuran

Isoniazid

Lithium

Minosin

Progesterone

Recreationial Drugs

Retin A Cream or Gel

Steroids

Sulphur

Tazorac

Testosterone

Thyroid Medication

Other Prescriptions

None

Are you currently using any type of protein supplement/powder? * *

Yes

No

Please indicate if you are allergic to any of the following: *

Select all that apply.

Benoyl Peroxide

Sulphur

Latex

Aspirin

None of The Above

Do you smoke? *

Yes

No

Have you been diagnosed with acne rosacea? *

Yes

No

What other treatments or procedures have you had on your skin? *

Select all that apply.

Corrective Peels

Dermabrasion

Electrolysis

Facial Waxing

Glycolic Acid Peels

Laser Hair Removal

Microdermabrasion

Plastic Surgery

Skin Cancer Removal

Other

None of the Above

Have you ever had an allergic reaction to any topical products? *

Yes

No

Do you use fabric softener or dryer sheets? *

Yes

No

Not Sure

Are you currently under a lot of stress? *

Yes

No

Somehwat

Do you pick at your skin? *

Yes

No

Sometimes

Which of the following do you eat on a fairly regular basis? *

Select all that apply.

Fast Food

Milk and/or Cheese

Peanut Butter

Seaweed/Kelp

Sugary Foods

Sushi

Salty Foods

None of the above

Phone *

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###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How did you hear about Valeria Zentner Skin Care? *

Select all that apply.

Advertisement

Citysearch

Esthetician

Friend/Relativve

Google

Newspaper Article

Yahoo Answers

Yelp

Face Reality Skincare

Other