La Vie Spa & Salon

Skin Balancing Facial - Services

Name:
Email Address:
Date
Are you currenetly under a physician's care for any skin condition?	Yes No
If yes, please explain briefly..
Your physicians name:
Contact Info:
Are you currently on any medication?	Yes No
Please List
List all nutritional or daily supplements that you are currently taking:
Please list all allergies:
Have you ever had a facial before?	Yes No
If so, date of last facial
What are your main concerns?
Do you have a heart condition?	Yes No
If yes, please explain:
Do you have a pacemaker?	Yes No
Do you have metal implants, including surgical clips?	Yes No
Where? How long?
Have you had a hysterectomy?	Yes No
Are you on any type of hormones?	Yes No
What kind?
Date of last menstrual cycle?
Do you excersize?	Yes No
How often? How long?
Do you smoke?
How much?
Do you drink alcoholic beverages?	Yes No
How much? How often?
Do you drink caffeinated beverages?	Yes No
How much? How often?
How much water do you drink daily?
What is your stress level on a daily basis?
Type of skin	Normal Dry Oily Sensitive
Is your skin experiencing any of the following?	Lines and wrinkles Acne Rashes Tightness Uneven tone Large Pores Blackheads Redness Dark spots Flaking or peeling Other
What are your breakout tendencies?	Rarely Occasionally Frequent