Kathi Jo Skin Care Clinic in Scottsdale, Arizona: Microdermabrasion Specialist

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1) How are you caring for you skin?

Soap: AM PM Brand:

Moisturizer: AM PM Brand:

Cleanser: cream lotion Brand:

Masque: clay non-setting Brand:

Toner: AM PM Brand

Scrub: daily weekly Brand

Sunscreen: daily occasionally Brand

Alpha hydroxy acid Brand

2) Have you ever had a professional facial before? Yes No

If yes, were you pleased with the result? Yes No

Date of your last skin treatment:

3) Are you currently, or within the last year, under a physicians care? Yes No

4) Have you undergone any surgery in the last 9 months? Yes No

If yes, please explain briefly:

5) Please define any health problems (past or present):

Asthma Heart Problems Hysterectomy Diabetes High Blood Pressure

Pacemaker Epilepsy Hormone Imbalance Other:

6) Do you have any metal pins, devices, etc. in your body? Yes No

7) Are you using Retin-A? Yes No

Have you ever been on Accutane? Yes No If so, when?

Have you had Botox injections? Yes No

Collagen Injections? Yes No

8) Please list all medications and vitamins that you are taking regularly:

9) Do you have any special skin problems? Yes No

If yes, please explain briefly

10) Do you smoke? Yes No How much?

11) How much water do you consume daily?

12) Have you ever experienced any claustrophobia? Yes No

13) Have you ever experienced sinus or allergy problems? Sometimes Never

14) Do you prefer a massage to be firm or light in pressure?

15) Do you take any, sedatives pain killers sleeping pills dieuretics

16) Do you have any known allergies? cosmetics pollens foods animals

Referred by: Friend Advertisement: newspaper yellow pages magazine

Thank you for your cooperation and enjoy your salon treatment!

Signature * Date

(480)425-7225
7310 E Sixth Ave.
Scottsdale, AZ 85251