APPLICATION

1. General Information 

 • Full Name 

 • Age 

 • Gender 

 • Contact Information

 

 2. Medical History

 • Do you have any chronic medical conditions (e.g., diabetes, hypertension)? If yes, please specify. 

 • Are you currently taking any medications? If yes, please list them. 

 • Do you have any known allergies? If yes, please specify. 

 • Have you ever had any dermatological conditions (e.g., eczema, psoriasis, acne)? If yes, please specify. 

 • Have you ever undergone any dermatological treatments or procedures? If yes, please specify.  

 

3. Skin Care Routine 

 •What is your current skin care routine (products used and frequency)?

 • Do you use any prescription skin care products? If yes, please specify.

 • How often do you exfoliate your skin?

 • Do you use sunscreen daily? If yes, what SPF? 

 • Do you have any skin sensitivities or reactions to specific products? If yes, please specify.

 • Do you use topical Vitamin C products?

 • Do you use Retin A?

 

 4. Lifestyle and Habits

 • How many hours of sleep do you get per night on average? 

 • Do you have a consistent sleep schedule?

 • How would you describe your diet (e.g., balanced, high in junk food,processed foods, vegan, etc.)? 

 • How often do you consume fruits and vegetables?

 • Do you take any dietary supplements? If yes, please specify.

 • How often do you exercise per week? 

 • Do you smoke or use tobacco products? 

 • Do you consume alcohol? If yes, how frequently? 

 

 5. Sun Exposure

 • How often are you exposed to direct sunlight (e.g., daily, weekly, rarely)?

 • Do you use sunscreen regularly? If yes, what SPF? 

 • Have you ever had sunburn or skin cancer?

 

6. Stress and Mental Health 

 • How often do you experience high levels of stress?

 • What methods do you use to manage stress (e.g., exercise, meditation, hobbies)? 

 • How effective are these methods for you? 

 • Have you been diagnosed with any mental health conditions (e.g., depression, anxiety)?

 

 7. Water Intake

 • How much water do you drink daily?

 • Do you feel adequately hydrated?

 

 8. Commitment to Protocol 

 • Are you willing to follow a strict skin care regimen as prescribed by Innovaes Regenerative Sciences? 

 • Are you able to attend regular follow-up appointments?

 • Are you open to making lifestyle changes if recommended by your dermatologist? 

 

 9. Specific Concerns and Goals 

 • What are your primary skin concerns (e.g., acne, wrinkles, hyperpigmentation)? 

 • What are your goals for your skin care treatment?