FACIAL QUESTIONNAIRE


Profile

Name:  

DOB:  

Phone Number:  

Gender:  

Occupation:  

Skin History

How would you describe your skin type?

 

What condition would you like to improve about your skin? Please check all that apply

If Other, describe here  

Approximately when was your last your facial?:   

How often do you get facials?:  

Describe generally ideally what you would like to achieve with your skin  

Please describe any any exfoliation i.e. chemical peels, scrubs, retinol you have done within the last week? It is recommended to stop exfoliants at least 48 hours and ideally 1 week prior to your facial.   

Which one of the following best describes your skin?

 

Health History

What is your ethnic background?  

Have you seen a dermatologist in the past year? choose one

 

Are you currently taking any medication or supplements we should be aware about? Please list them here, if none enter none:  

Please list any illnesses or pre-existing conditions that we should be aware about here:  

ALLERGIES: please list any known allergies here:  

Home Care

What skin products are you currently using at home. Check all that apply

 

Do you use sun protection?

 

Do you sun bathe?

 

Do you use the tanning boothe?

 

Leave this empty:

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Signature Certificate
Document name: FACIAL QUESTIONNAIRE
lock iconUnique Document ID: dfa99b6693f5fc70c52924a42370912c6b58ec5e
Timestamp Audit
December 16, 2025 2:07 pm CSTFACIAL QUESTIONNAIRE Uploaded by The Bello Group Inc - chiomafarmersbranch@gmail.com IP 97.134.209.83
December 16, 2025 2:09 pm CSTEbele Chioma - ebele.okocha@gmail.com added by CHIOMA Co. Concierge - chiomafarmersbranch@gmail.com as a CC'd Recipient Ip: 72.110.53.134
December 16, 2025 3:35 pm CSTEbele Chioma - ebele.okocha@gmail.com added by CHIOMA Co. Concierge - chiomafarmersbranch@gmail.com as a CC'd Recipient Ip: 72.110.53.134
December 19, 2025 10:47 am CSTEbele Chioma - ebele.okocha@gmail.com added by CHIOMA Co. Concierge - chiomafarmersbranch@gmail.com as a CC'd Recipient Ip: 72.110.53.134
December 19, 2025 10:47 am CSTCHIOMA Farmers Branch - chiomafarmersbranch@gmail.com added by CHIOMA Co. Concierge - chiomafarmersbranch@gmail.com as a CC'd Recipient Ip: 72.110.53.134
February 16, 2026 9:05 am CSTEbele Chioma - ebele.okocha@gmail.com added by The Bello Group Inc - chiomafarmersbranch@gmail.com as a CC'd Recipient Ip: 97.134.209.83
February 16, 2026 9:05 am CSTCHIOMA Farmers Branch - chiomafarmersbranch@gmail.com added by The Bello Group Inc - chiomafarmersbranch@gmail.com as a CC'd Recipient Ip: 97.134.209.83
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