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Skin Care History Questionnaire and Waiver Mobile App

Complete this Skin Care History Questionnaire so your Skin Care Specialist will have a better understanding of your general medical history and lifestyle so your skin care needs can be accurately analyzed.

This app is customizable so you can detail any skin conditions, skin diseases, and fine lines and wrinkles you may have. You can also list your current skin care regimen, skin care products you use, and other health care and risk factors concerns.

You can download this app onto an iPhone, iPad, or Android device. This survey questionnaire is saved in the GoCanvas Cloud and can be printed or emailed as a PDF if you need to send it to a skin care specialist, health care provider, or keep for your medical history records.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Skin Care History Questionnaire and Waiver Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico statictext

    Please answer the following questions so that your Skin Care Specialist may have a better underst...

  • Ico date

    Date

  • Ico textbox

    Name

  • Ico textbox

    Address

  • Ico textbox

    City

  • Ico dropdown

    State

  • Ico textbox

    Zip

  • Ico textbox

    Home Phone

  • Ico textbox

    Business Phone

  • Ico textbox

    Cell Phone

  • Ico textbox

    Date of Birth

  • Ico textbox

    E-mail Address

  • Ico textbox

    What type of work do you do?

  • Ico dropdown

    Have you seen a dermatologist in the past year?

  • Ico multiline

    If yes, list dermatologist’s name, contact info and reason for visit

  • Ico dropdown

    Are you presently under a physician’s care?

  • Ico multiline

    If yes, list physician’s name and reason for visit

  • Ico dropdown

    Are you currently taking any medications?

  • Ico multiline

    If yes, please list

  • Ico textbox

    What is your genetic background?

  • Ico dropdown

    How is your general health?

  • Ico dropdown

    Please rate your stress level from 1-5 (5 being the highest)

  • Ico statictext

    Please check the following conditions you have or had experienced

  • Ico checkbox

    hypertension

  • Ico checkbox

    metal plate

  • Ico checkbox

    diabetes

  • Ico checkbox

    fainting

  • Ico checkbox

    cold sores

  • ...and More!

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