Client Consultation Name* First Last Email* Phone*Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Are you single?YesNoMarried?YesNoAddress Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Colorado ZIP Code Employer - OccupationDoes your job require that your work outdoors?YesNoDid someone refer you to Joyful Skin?What would you like to achieve from your treatment today?Your Skin CareHave you ever had a facial treatment before?YesNoWhen?Have you ever had a spa treatment before?YesNoWhen?Select treatments below Massage Salt Glow Seaweed Wrap Moor Mud Body Wrap Other Which of the following best describes your skin type? Creamy complexion - Always burns easily, never tans Light complexion - Always burns, tans slightly Light/Matte complexion - Burns moderately, tans gradually Matte complexion - Seldom burns, always tans well Brown complexion - Rarely burns, deep tan Black complexion - Never burns, deeply pigmented Do you have any special skin problems or concerns pertaining to your face or body?Please specifyHave you ever had any chemical peels, laser or microdermabrasion? Yes No Do you use Retin-A, Renova, Adapalene Hydoxyl Acid or Retinol/Vitamin A derivative products? Yes No Have you used any of these products in the last 3 months? Yes No Have you used an acne medication? Yes No What skin care products are you currently using?Please share any: (list brand when known) Soap - Toner - Mask - Eye Product - Cleanser - Day Moisturizer - Exfoliator - Scrubs Shower Gels - Body Lotions - Sunscreen - SPF - Night Moisturizer/Cream - Other - Makeup ProductsHave you recently used any self-tanning lotions, creams or treatments? Yes No Have you used any of the following hair removal methods in the past 6 weeks?Select and that apply Shaving Waxing Electrolysis Plucking Tweezing Stringing Depilatories What areas of concern do you have regarding your skin?Select and that apply and explain Breakouts/Acne Excessive oil/shine Broken capillaries Sun spot/liver spot/brown spot Sun damage Dull/dry skin Dehydrated Blackheads/Whiteheads Rosacea Rosacea Unever skin tone Wrinkles/fine lines Flaky skin Other Please ExplainEyes Dehydrated Wrinkles Puffiness Dark Circles Other Lips Dehydrated Cracked/Chapped Lips Other Have you ever had an allergic reaction to any of the following?Select any that apply and explain Cosmetics Food Sunscreens Pollen Fragrance Latex Medicine Animals Iodine AHAs Shellfish Drugs Other If yes, please explainWhat SPF do you use on your face?How often and when?What SPF do you use on your body?How often and when?Have you had any recent tanning bed or sun exposure that changed the color of your skin? Yes No Have you experienced Botox, Restylane or Collagen injections? Yes No Female Clients OnlyAre you taking oral contraceptives? Yes No Have you had recent changes to or from a contraceptive treatment? Yes No Are you pregnant or trying to become pregnant? Yes No Are you lactating? Yes No Any menopause problems/challenges? Yes No Are you undergoing any hormone replacement therapy? Yes No Male Clients OnlyWhat is your current shaving system? Wet Shave Electric Do you experience irritation from shaving? No Yes Ingrown Hairs Please use this space to complete answers where space was insufficient. (Please indicate the question.)Future Appointments / ContactMay I call you at your home, work or cell phone number to confirm future appointments? No Yes May I contact you via mail/email about future promotions and news? No Yes 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 that withholding information or providing misinformation may result in contraindications and/or irritation to the skin treatments received. The treatments I receive from Joyful Skin are voluntary and I release this institution and/or skin care professional from liability and agree to terms of service.** I have read and agree to the previous statement. What does 2 + two = ?*Our SPAM blocker, thank youPlease enter a number from 4 to 4.