Dermalogica Consultation Form

Welcome to the Nirvana Beauty Online Dermalogica Survey.

1. List any Medications or vitamins that you take regularly
Medications
Vitamins
2. Do you smoke?	Yes No
3. Had Chemical Peel?	Yes No
If yes when ?
4. Laser resurfacing?	Yes No
If yes when?
5. Botox?	Yes No
If yes When?
6. AHA'S?	Yes No
If yes When?
7. Collagen/Hyalauron	Yes No
If yes When?
8. Use Retin-A	Yes No
9. Ever used the Acne drug. Accutane?	Yes No
10. Follow a restricted diet?	Yes No
11. Exercise regularly?	Yes No
12. Have regular sleep?	Yes No
13. Do you suffer from eczema or psoriasis?	Yes No
14. What temperature of water do you use to cleans with?
	Cool Warm Hot
15. Do you have any special skin problems pertaining to your face?
if yes, Specify
16. Do you have any special concerns pertaining to your body?
if yes, Specify
17. What type of skin care product are you currently using?
Soap Toner Mask Cleanser Moisturizer Scrub/peel AHA'S
Female Clients Only (optional) :
18. Are you taking oral contraception?	Yes No
19. Are you pregnant or trying to become pregnant?
	Yes No
20. Are you lactating?	Yes No
male Clients Only :
21. What is your current shaving system?	Wet Electric
22. Do you ever experience irritation from shaving?
	Yes No
23. Do you experience ingrown hair?	Yes No
Oil Secretion
24. Do you experience breakthrough oily shine during the day?
	Yes No
25. Do you experience skin break outs?	Yes No
Moisture Hydration
26. How much plain water do you consume daily?

27. Do you take laxatives or diuretics?	Yes No Occasionally
28. How many alcoholic beverages do you consume weekly?
	1-3 4+
29. Do you ever experience these conditions on your skin?
	Flakiness Tightness Obvious dryness
30. Do you use a sun block on your skin?	Yes No
If so, how often and what spf?
Capillary activity
31. Do you burn easily in moderate sunlight?	Yes No
32. Do you blush easily when nervous?	Yes No
33. Do you have a tendency to redness?	Yes No
34. Have you ever suffered any sinus problems?
	Yes No
Nerve activity
35. Do you drink caffeinated beverages? (coffee, tea, soft drinks?) How many daily?
	times
36. Do you take any stimulants or slimming tables?
	Yes No Occasionally
37. Have you ever had a reaction to any of the following -
Cosmetics Medicine Iodine Pollen Food AHA'S animals Fragrance Sunscreen Others
Do you suffer from:
38. Normal/dry skin with fine lines/ageing?	No Moderate High
39. Uneven skin tone, hyper pigmentation?	No Moderate High
40. Sensitive, allergy prone skin?	No Moderate High
41. Broken capillaries?	No Moderate High
42. Scarring or post acne scarring?	No Moderate High

Your Name
Your Email