Shannon's Serendipity Skincare | Las Vegas

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Skin Health Questionnaire

Did you know that more than your skin type is needed to properly and effectively maintain your skin health? Get a treatment and product combination that is perfect for you, when you complete the Skin Health Questionnaire today.

Skin Health Questionnaire

Complete the following, as directed, as thoroughly and in as much detail as possible.

Step 1 of 4

25%

Name*
First Last
Phone Number*
Address
Street Address Address Line 2 City Nevada ZIP Code
Email*
BIrthdate
Month
Day
Year
Emergency Contact
Relation to Contact
How Did You Hear About Us?*
Occupation
Interests
Please Indicate Which Services Your Are Interested In*
- Select All
- Skin Care Consultation/Advice
- Home Care Products
- Clinical Treatments
- Age Management
- Acne Treatment/Management
- Rosacea
What Do You Wish to Change About Your Skin?*

Medical History
Are You Currently or Have You Previously Experienced Any of the Following*
- None
- Heart Condition
- Pacemaker
- Headaches
- Anemia
- Low Blood Pressure
- Cancer
- Thyroid Condition
- Kidney Problem
- High Blood Pressure
- Arthritis
- Hemophilia
- Asthma
- Diabetes
- Hypo/Hyper Glycemia
- Hepatitis
- Herpes Simplex
- AIDS/HIV Positive
- Contact Lenses
Do You Have an Autoimmune Disorder*
- Yes
- No
Type of Autoimmune Disorder(s)*
If you are currently experiencing or being treated for any health-related condition, please describe:
If you have had a surgical procedure, please describe where on your body the surgery was performed
List any allergies or skin treatment products you have used that have caused unexpected reactions or side effects
List all over-the-counter and prescription medications you are currently taking
Indicate If You Have Every Used Any of the Following Medications for Skin Treatment*
- None of These
- Accutane
- Cortisone
- Staticin
- Benzoyl Peroxide
- Retin A
- Sulfer
- DesquamX
- Zerac
- Fosdex
- Glycolic Acid
- Salicylic Acid
- Lactic Acid
- Renova
- Clindamycin
- Tazoratene
- Metrogel
What Conditions Were You Treating With This Medication(s)*
When Was the Last Time You Used These Medications*
Hormone Information
Gender*
- Female
- Male
Are You Pregnant
- Yes
- No
- I'm Trying
Are Your Planning A Pregnancy In the Future*
- Yes
- No
Do You Have Regular Menstrual Cycles*
- Yes
- No
- Going Through Menopause
If You Are Currently Undergoing Hormone Therapy, Please Describe
Do You Have Any Hormone Imbalance*
- Yes
- No
Have You Undergone Surgical Menopause (Hysterectomy)*
- Yes
- No
Skin Self-Analysis
What Skin Care Products Are You Currently Using
Are You Wearing a Daily Sunscreen*
- Yes
- No
Type & SPF*
What Is Your Skin Type*
- Oily or Acne Prone
- Dry
- Normal
- Sensitive
Have Your Ever Been Treated or Are You Currently Being Treated for a Skin Condition*
- Yes
- No
What Condition*
How Did You Treat the Condition*
- Dermatologist
- Aesthetician
- Self Treated from Drug Store
- Self Treated from Dept Store
Were You Happy With The Results*
- Yes
- No
Are You Currently Treating or Being Treated for Any Skin Condition?*

Lifestyle & Stress Analysis
Do You Come Into Contact With Any Chemicals at Work*
Do You Work Around Excessive Heat or Cold*
Do You Use Hot Tubs or Saunas? How Often*
Average Hours of Sleep*
Please enter a number less than or equal to 20.
What is Your Stress Level (1-10)*
How Many Minutes A Day Are Your Exposed to Sunlight?*
Please enter a number from 0 to 1000.
What is Your Ancestory*
What Are Your Mother's and Father's Ancestory*
Please Indicate Any of the Following that Apply to Your Eating Habits*
- Select All
- Fast Food
- Baked Bread
- Salty Foods
- Seafood
- Dairy Foods
- Ethnic or Spicy Foods
- Peanuts
- Peanut Butter
- Soy
How Much Water Do You Drink Per Day*
How Many Caffeinated or Carbonated Drinks Do You Consume Daily*
Do You Smoke Tobacco Products*
- Yes
- No
Average Alcohol Consumption Per Week*
Have You Changed Your Brand of Skin Care Products in the Last Year and Why?*

Current Skin Care
Current Skin Care Routines*
- Cleansing
- Bleaching
- Acne Products
- AHA
- Retin-A
- Exfoliant/Type
- Treatment
- Moisturizing
- In-Clinic Treatment
Select All That Apply
Cleansing Routine*
Bleaching Routine*
Acne Routine*
AHA Routine*
Retin-A*
Exfoliant/Type Routine*
Treatment Routines*
Moisturizing Routine*
In-Clinic Treatment*
Photo Dermatology
Areas of Concern*
Acknowledgement of Payment*
- I Understand and Agree That I am Ultimately Responsible For Payment in Full for Services Received
By Submitting This Form You Are Requesting A Service and Consenting to Services
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Waxing Services

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Facial Services
Waxing Services
Anti-Aging Treatments
All Facials
Treatment Masks
Micro-Needling
Chemical Peels
Deep Pore Cleaning
Rejuvenated Facial
Anti-Aging Facials
Corrective Facials
Acne Treatment
Client Forms
Contact
Make an Appointment
Pre and Post Care
How the Sun Sees You

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