Client Questionnaire
Client Handout: Client Questionnaire
YOUR INFORMATION
Name Age DOB Ethnicity
Address City State
Zip Cell Phone Other Phone
Email
Please indicate if you have used any of the medications or drugs listed below in the last 2 years, when they
were used, and for how long you used them.
MEDICATION WHEN HOW LONG MEDICATION WHEN HOW LONG
Antibiotics (oral)
Antibiotics (topical)
Accutane
Benzoyl Peroxide
Retin-A, Tazorac, Differin
Thyroid medication
Blood Thinning Meds
Please list any other medications or drugs listed that you have used in the past 2 years and include when
they were used, and for how long you used them:
MEDICAL HISTORY (PLEASE CHECK ALL THAT APPLY)
Herpes Simplex HIV/AIDS Hemophilia
Eczema Thyroid Problems Lupus
Psoriasis Hormone Prolems Anemia
Hepatitis Hysterectomy High Blood Pressure
Cancer Ovary(ies) Removed Diabetes
Staph Infection/MRSA Pacemaker Metal Pins in Body
YOUR PRIMARY CARE PHYSICIAN:
Name: Phone:
Are you under a dermatologist’s or other physician’s care? Yes No
If yes, doctor’s name:
© 2024. Face Reality, LLC. All Rights Reserved. Updated 10/14/23.
1
LIFESTYLE CONSIDERATIONS
Client Handout: Client Questionnaire
Have you ever had any reaction to any products or anything you have put on your face? Yes No
If yes, what products?
Please check any of these you are allergic to: Sulfur Aspirin Latex
List any other allergies you know of:
Do you smoke/vape? Yes No If yes, what do you smoke
Do you use fabric softener or fabric softener sheets in the dryer? Yes No
Do you swim in a chlorinated pool? Yes No
Do you work around chemicals, tars, oils, grease or inks? Yes No
Occupation: Do you work nights? Yes No
Are you currently under a lot of stress? Yes No (common stress triggers: job loss, new job,
wedding, death in the family or close friend, graduation, long commute, heavily scheduled)
Do you use birth control pills, shots or use an IUD? Yes No
If so, which do you use? What brand of pill?
Are you pregnant or nursing? Yes No
Do you have shaving irritation on your face? Yes No
What type of razor do you use for shaving (i.e, double blade, triple blade, rotary)
DIET - DO YOU CONSUME THE FOLLOWING?
FOODS HOW OFTEN PER WEEK FOODS HOW OFTEN PER WEEK
Fast Food Peanuts
Processed Food Sushi
Salty Snacks Kelp and Seaweed
Milk/Yogurt Miso Soup
Cheese Soy
Whey or Soy Vitamins/
Protein Supplements
Peanut Butter Seafood
© 2024. Face Reality, LLC. All Rights Reserved. Updated Updated 10/14/23.
2
Have you ever used any Face Reality Skincare products? Yes No
Client Handout: Client Questionnaire
If yes, please list the products:
Are you still currently using Face Reality Skincare products? Yes No
PRODUCTS CURRENTLY USING - PLEASE PROVIDE PRODUCT NAMES
CLEANSER
TONER
SERUMS
MOISTURIZERS
SUNSCREEN
MASK
FOUNDATION
BLUSH
EXFOLIANT (ACIDS, SERUMS,
SCRUBS)
ACNE MEDICATIONS
ANYTHING ELSE?
OTHER TREATMENTS: WHAT ELSE HAVE YOU DONE FOR YOUR SKIN IN THE LAST 90 DAYS?
TREATMENT WHEN? WHERE?
Chemical Peels
If so, what kind:
Microdermabrasion
Dermabrasion
Laser Hair Removal
Laser Rejuvenation/Resurfacing
Skin Cancer Removal
Facial Waxing
Electrolysis
Other:
How did you hear about us?:
© 2024. Face Reality, LLC. All Rights Reserved. Updated 10/14/23.
