COVID-19 Health & Safety Measures
Updates to our Services
Instagram
Facebook
Skip to content
CALL (778) 228-4275
Classic Facials
High Tech Skin Treatments
Microdermabrasion
SkinPen® Microneedling
Microcurrent
LED Therapy
Cosmetic Acupuncture
Traditional Acupuncture
Routine Matters Blog
Skincare
BOOK ONLINE
Classic Facials
High Tech Skin Treatments
Microdermabrasion
SkinPen® Microneedling
Microcurrent
LED Therapy
Cosmetic Acupuncture
Traditional Acupuncture
Routine Matters Blog
Skincare
BOOK ONLINE
Cosmetic Acupuncture & Facial Cupping Intake Form
Kathryn Sawers
2023-03-07T23:25:02+00:00
Cosmetic Acupuncture and Facial Cupping Intake Form
Cosmetic Acupuncture Form
Cosmetic Acupuncture and Facial Cupping Intake Form
Date of birth
*
MM slash DD slash YYYY
Name
*
First
Last
Phone
*
Please provide us with the phone number for which you are most easily reached.
Email
*
How did you hear about us?
*
friend/family referral
Varnish
internet search
social media
media article
advertising
Referral
If you have been referred, please let us know by whom so we can thank them.
Have you had acupuncture before?
Yes
No
Occupation
Your Health
If yes, please specify.
Have you had any health problems in the past or present?
*
Yes
No
If yes, please specify.
List any medications, vitamins, diuretics, slimming pills, Isotretinoin, etc. that you take regularly.
*
Do you have any allergies?
*
Yes
No
If yes, please specify.
Do you any problems with bleeding or bruising?
Yes
No
Do you follow a restricted diet?
Yes
No
If yes, please specify your restrictions.
Do you smoke?
Yes
No
On average how much water do you consume daily?
On average how many alcoholic beverages do you consume weekly?
On average how many caffeinated beverages do you consume daily? (coffee, tea, soft drinks)
Do you exercise regularly?
Yes
No
If yes, please specify how many times per week.
Do you wear contact lenses?
Yes
No
Do you sunbathe or use tanning beds?
Yes
No
If yes, how often?
Have you experienced claustrophobia?
Yes
No
Within the last 9 months have you been undergone surgery?
Yes
No
What is your pain threshold?
1 being quite low and 5 being quite high.
Please enter a number from
1
to
5
.
What massage pressure do you prefer?
Light
Medium
Firm
Your Skin
Check off all the specific skin concerns/ challenges that apply.
fine lines
wrinkles
redness
brown spots
loss of firmness
acne
other
Please share any further details regarding your goals for your visit.
What skin care products are you currently using?
bar soap
cleanser
toner/facial mist
moisturizer
face oil
serum
mask
eye products
exfoliator
primer
foundation
Other makeup:
Body products
bar soap
shower gel
scrubs
oil
body moisturizer
depilatory products
self-tanner
Do you use facial tools? eg: gua sha, facial rollers, microneedler, nuface, cleansing brush etc.
Yes
No
If yes, please specify which and how often:
Have you ever had:
chemical peel
microdermabrasion
laser
intense pulsed light
dermaplaning
microneedling
If yes, please specify which and when you last received this treatment.
Do you use: Retin-A, Renova, Adapalene or any other prescription skin products?
*
Yes
No
If yes, was it in the last 3 months?
Yes
No
Are you currently using products that contain any of the following ingredients?
hydroxy acids (glycolic, lactic, salicylic etc.)
exfoliating scrubs
vitamin A derivatives (Retinol, Retin-A, Retinyl Palmitate)
Do you ever experience these conditions on your skin?
flakiness
tightness
obvious dryness
Do you use sunscreen daily?
Yes
No
If yes, please specify what SPF you use for both face and body.
Choose which best describes your skin’s response to the sun.
always burns, blisters and peels
often burns, blisters and peels
burns moderately
burns rarely, if at all
never burns
Have you ever been diagnosed with melasma?