Within the past year, have you been under a Physicians care?

If yes, please explain.

Have you had any surgeries within the past 5 years?

If yes, please explain:

Any health problems past or present?

If yes, please explain.

Have you recently (the past 3 months) had injectable fillers (Juvederm, Restylane etc…) or Botox in your face or body?

If yes, where and when?

List all Medications you are currently taking:

List of all allergies/allergic:

Are you pregnant, Trying to get pregnant, Hormone Therapy, Contraceptives?

If yes, please explain

Do you Smoke?

Exercise regularly?

Do you wear SPF

If no, please explain why

What method of exfoliation are you currently using for your face & body?

Have you had Chemical Peels, Microdermabrasion, Resurfacing Treatment, or Laser?

If yes, please explain.

Have you past or present, used Accutane, Retin A, Trentinoids?

If so, when & for how long.

Are you currently using any Glycolic, Salicylic, Lactic, Hydroxy Acids, or Vitamin A?

If yes, please list below

What skincare line are you currently using?

Have you ever had any reactions to: Cosmetics, medicine, iodine, shell fish, hydroxy acids, animals, fragrances, sunscreens?

If yes, please explain.

What is your pain threshold?

Rate on scale of 1-5. (1 being minimal - 5 severe)

What are you goals pertaining to your face and body?

How do you prefer massage pressure?

Light, Medium, Firm

Rank in order of importance 1-5 (1 being the most 5 being the least)

Reduction of Fine Lines

Reduction of brown spots

Reduction of oil/acne

Acne scars deminshed

Reduction of redness

Health Questionnaire