SKIN CONCEPTS
Skin Care
and
Appearance Center

Located in lovely Waimea on the Big Island of Hawaii
Local: 808.881.9700 Toll Free: 886.881.9700

Hours - Mon, Wed, Fri - 10am to 5pm, Tues & Thurs noon to 5pm, Evening Appointments Available
Saturday 9am to noon, Afternoon Appointments Available.
Yes, you can SHOP ON LINE from our skin care catalog!
Simply click on the blue links to your left to view a complete product line and make your selections.


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Skin Care Consultation Questionnaire

Name:
Date :
Email :
Phone#:
Age Under 21  21-30  31-40  41-50  51-60  Over 60
Skin Care History
1. What Three Things would you most like to change about your skin?
2. How much time are you willing to devote to your skin in the morning and evening and weekly?
3. What products are you currently using to care for your skin?
4. What results are you experiencing with these products?
Client History
1. List any medications and vitamins that you take regularly.
2. Do you smoke?
 Yes  No
3. Have you had chemical peels?
 Yes  No
Use Retin-A?
 Yes  No
Ever use the acne drug Accutane?
 Yes  No
6. Exercise Regularly?
 Yes  No
7. Have regular sleep patterns?
 Yes  No
8. What is your stress level?
 Low  Moderate  High
Oil Secretion
1. Do you experience breakthrough oily shine during the day?
 Yes  No
2. Do you experience skin break-outs?
 Yes  No
3. If yes, where are the break-outs usually located?
 Hairline  Forehead  Under Eye  Chin  Cheeks  Jaw Line
Moisture Hydration
1. How much plain water do you consume daily?
 1-4 8 oz. glasses  4-8 8 oz. glasses  8-10 8 oz. glasses
2. Alcohol consumption:
 None  Low  Moderate  High
3. Do you consume more than two caffeinated beverages a day?
 Yes  No
4. Do you ever experience tightness or flaking of your skin?
 Yes  No
5. Do you use a sun protectant when out of doors?
 Yes  No
Nerve Activity
Have you ever reacted to any of the following?
 Cosmetics  Medicine  Iodine  Pollen  Food  AHA's  Animals  Fragrance  Sunscreens  Other
Please email or call 808-881-9700 to set up a complimentary phone consultation. Please indicate the best time for us to contact you.




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For more information:
Skin Concepts
65-1188 Mamalahoa Hwy Suite #3
Kamuela, HI 96743, HI 96743 US
Email: skinconcepts@earthlink.net
808-881-9700

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