First & Last Name *

Address *

City *

State *

Zip Code *

Phone *

Date of Birth *

Age *

How would you categorize your skin? *

Normal
Dry
Oily
Combination
Sensitive
Red
Compromised

Do you have a tendency towards redness? *

Never
Sometimes
Always

Do you experience skin breakouts? *

Never
Sometimes
Always

What type of breakout do you experience *

White heads
Black heads
Inflamed never comes to a head
Deep cystic
Maturation arrest / when skin is pulled tight, tiny white bumps appear

Do you have a menstrual cycle? *

Are your menstrual cycles regular? *

Do you track your menstrual cycle? *

Do you take birth control? *

What form / brand of birth control do you take? *

When you experience an acne breakout how often do you pick? *

Never
Sometimes
Always

After you experience an acne breakout when the skin is healed is there a brown spot left in its place? (Post inflammatory hyperpigmentation) *

Never
Sometimes
Always

Does your skin feel rough or leathery? *

Never
Sometimes
Always

Do you experience dryness, flakiness, or tightness? *

Never
Sometimes
Always

When exposed to the sun do you *

Always burn / never tan
Sometimes burn / sometimes tan
Always tan / never burn

What are your skin care concerns? *

Clear skin / Acne breakouts
Firm skin / Lacticity
Bright skin / Pigmentation, dull
Anti-aging / Aging skin
Rosacea skin / Red
Compromised skin / damaged, over exfoliated

Have you had a Face Reality Acne Consultation? *

Do you have current Face Reality skincare routine? *

List your morning routine / brands * Cleanser, Toner, Exfoliants/Scrub, Serums, Masks, Correctives, Moisturizer, Eye care, Sunscreen

List your evening routine / brands * Cleanser, Toner, Exfoliants/Scrub, Serums, Masks, Correctives, Moisturizer, Eye care

If you were to skip a step of your morning or evening routine which step would it be? *

What type of skincare routine are you wanting or needing at this time in your life? *

Basic 1-4 Steps
Intermediate 3-5 Steps
Advanced 4-7 Steps

Do you purchase skin care monthly or quarterly *

Monthly
Quarterly

What is your monthly budget for skin care *

$ 50
$$ 100
$$$ 150-175
$$$$ 200+

Are you currently using any products that contain the following ingredients? (Check all that apply) *

BHA
AHA
Glycolic
Salicylic
Lactic Acid
Vitamin A
Tretinoin
Differin
Benzoyle

Are you currently using any prescription products (Examples: Accutane, Hydrocortisone)? If yes, when did you last take it? *

Are you currently taking any vitamins or supplements? *

Do you exercise and how often? *

Have you ever received a skincare treatment before? If So where and what type of treatment? *

Do you have permanent makeup or tattoos? If yes, where? When did you have this procedure done? Did you have any reaction to this service? *

Have you had any direct sun exposure in the last 10 days? *

Do you tan in a tanning bed? If yes, how often? *

Do you have any of the following medical conditions? (Please check all that apply)

High blood pressure or heart conditions.
Taking blood-thinners such as aspirin or similar medication.
Diabetes.
Pregnant or lactating.
Glaucoma.
Herpes simplex.
Certain skin conditions e.g. rashes, blisters, psoriasis, or eczema.
Taking steroids such as cortisone, Accutane, Retin-A, or Renoval

Are you allergic to any of the following? (Please list all that apply) * Food, Medications, Other

Are you currently taking any medications? If Yes, Please list them below. *

Are you nursing, pregnant, or trying? *

Are you going through menopause? *

Do you experience irritation from shaving or waxing? Do you experience ingrown hairs? *

Did you receive waxing services within the last 72 hours? *

Signature *

Date Completed *

Thanks for getting in touch!

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

Thanks for getting in touch!

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

Skin Health Form

Thanks for getting in touch!

Thanks for getting in touch!

Collection: Pure Encapsulations

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