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Skin Discovery Session Form

Section 1: Basic Info

Date of Birth
Month
Day
Year

Emergency Contact Name and Phone

Section 2: Skin Concerns & Goals

3 Months

6–12 months

Section 3: Medical History & Known Conditions

Please check all that apply:
Pregnant or breastfeeding?
Yes
No

Section 4: Genetic / Family Background

Do you scar or darken easily after breakouts or scratches?
Yes
No
Does anyone in your family deal with skin conditions (acne, pigmentation, sensitivity)?
Yes
No
Have you ever experienced keloids or hypertrophic scarring?
Yes
No

Dry, oily, combo, sensitive, etc.

Section 6: Lifestyle Snapshot

Daily stress level:
Low
Moderate
High
Do you drink alcohol regularly?
Yes
No
Are your bowel movements regular?
Yes
No
Do you exercise or sweat regularly?
Yes
No

Section 7: Hormones & Cycle (if applicable)

Do you experience breakouts around your menstrual cycle?
Yes
No
Do you take birth control or hormone therapy?
Yes
No
Have you started or stopped hormonal medication in the last 6 months?
Yes
No

Section 8: At-Home Skincare Routine

Section 9: Active Ingredient Use Check-In

Have you used the following in the last 30 days?

Section 10: Previous Treatments & Exposures

Are you regularly exposed to any of the following?

Section 11: Skin & Diet Connection

Section 12: Commitment & Preferences

Are you ready to stay consistent with skincare and appointments?
Yes
No
Please check all boxes:
Are you open to purchasing product recommendations to support your skin plan?
Yes
No
How committed are you to your results? (1–10 scale)
1 (not very likely)
2
3
4
5
6
7
8
9
10 (committed!)

Section 13: Consent & Acknowledgement

Please Check All Boxes
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