Client Intake Forms. What you need to know and the important questions to ask

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A thorough skin analysis and consultation sets the tone for the client relationship and is the key to your success. In order to provide your client with the most appropriate treatment, there are five essential forms that I feel are necessary to create client files. Using these forms will help build your relationship with the patients, establish clear communication, and gather necessary information to develop effective in-clinic and daily skin care regimens that ensure optimal client results.

Keep in mind that it is helpful to use a New Client Procedure Checklist that highlights the important information to be covered prior to a treatment and gives the clinician the order in which each step should take place (analyzing the skin, determining the appropriate professional treatment, etcetera).

sample-form-1The aesthetician should fill out:

  • Skin Analysis Form
  • Client Treatment Log

The client should fill out:

  • Personal History Questionnaire or
  • Medical History Form
  • General Consent Form
  • Chemical Peel Consent Form
    (when applicable)

It is also recommended that the skin care therapist maintain a separate consent form for each treatment including, but not limited to: Laser, LED Light Therapy, Microcurrent, Chemical Peel, Vascutouch and Radio Frequency Treatments. You may ask the client to review and sign before a series of treatments. If you are concerned about potential complications, ask the client to sign a consent form each visit prior to treatment.

sample-form-2The Medical History Form provides for full disclosure of pertinent client information that will enable the skin care therapist to develop a safe professional treatment plan as well as the home care treatment plan.

The General Consent Form is signed by the client the first time they visit the clinic and updated annually. This informed consent insures your client understands and consents in general to the treatments that will be performed. In addition the informed consent communicates the expectations of all pre- and post-procedure recommendations. This is especially important when performing more intensive treatments – such as lasers or chemical peels – in order to avoid complications.

The Chemical Peel Consent Form educates the client on how to treat their skin pre- and post-peel. This will help ensure patient compliance and reduce the incidence of complications.

The Skin Analysis Form is filled out by the aesthetician prior to the treatment. This form includes a checklist for:

  • Skin type and condition
  • Fitzpatrick Classification Scale 
  • Wood's Light observations 
  • Glogue Aging Skin Classification 
  • Rubin's Classification of Photo-Aging 
  • Kligman's Acne Classification 
  • Kligman's Rosacea Classification

This form should also include face diagrams with a section for comments to document specific areas of concern that correlate with the skin's condition. This kind of thorough documentation is vital to client compliance as your client will forget the condition of their skin when they first came to you. Detail any suggestions you make regarding series of treatments, add-on treatments performed, or at-home regimen changes. Take pictures with a digital camera to note any noticeable changes.
The Client Treatment Log is used to document data regarding the treatment performed. This can include the specific products used in the treatment protocol; number of layers applied of the chemical peel; sensitivity of client during the treatment; any visible signs of unexpected reactions; as well as any and all positive results.

doctor-patientThe Consultation Process
After reviewing the medical history and performing the skin analysis, discuss the client's concerns along with what you have assessed. Then recommend a treatment based on all the knowledge you have gathered through this process. Go through your checklist of skin type, skin color and skin condition. This kind of clinical intake creates a connection between your treatment recommendations and the client's concerns. Answers to the intake questions offer insights for how to develop a long-term treatment plan and manage the client's skin health. It is also vitally important for treatment safety and to avoid complications.
Keep in mind that the examination process can be very scary for most clients. Start your analysis with a compliment about the client's skin or one of their features; this will help to put them at ease.
When you complete your analysis, document your findings on the internal record as well as the home care guide for your client. Proper skin analysis is the key to developing an appropriate treatment plan and creating the client's expectation for future treatment sessions. Product and series sales also benefit from the analysis.
Having a skin analysis chart and treatment log on file is something that you can go back to and see the on-going treatment history. A well-kept chart can show client progress, changes, and important information. When you do not document what products or equipment you used in the treatment room, or what is going on with a client's skin, the next person to look at that chart may be missing important information that could be detrimental to the client's progress. Also, with multiple clients and weeks (or months) in between each treatment, it can be extremely easy to forget each client's individual needs and treatment protocols.
sample-form-3

The Charting Process
When you chart, there are some basic things you will need to do. The medical way to remember what to chart is S.O.A.P.
S stands for subjective information, things that the client feels, complains about, problems they present, and so on. For example, has their skin felt itchy or have they felt dry or dehydrated lately?
O stands for objective, which are things you actually see or observable findings. For example, do you see a blotchy and hyperpigmented skin tone or dry, dehydrated and flaking skin with fines lines?
A stands for assessment. What treatments are you going to do to target the concerns?
P stands for plan. What are the short- and long-term plans you need to develop to resolve their skin health issues? Will they return for future treatments? What will be the at-home regime?

The Important Questions
The questions included on the client intake forms should cover all the things the aesthetician needs to know to carry out safe and effective treatments. Certain procedures can have precautions and contraindications. It is necessary to include a number of questions regarding a person's medical history, product use, and lifestyle in order to prevent adverse reactions and to decide if they are a good candidate for a certain treatment.

sample-form-4Aestheticians should include the following questions in the Medical History Form:

  1. What are your expectations from your treatment today? It is important that the client understands the level of results attainable in a certain session, especially a first-time client. The easiest way to gauge a client's expectation is to simply ask. If they have unrealistic expectations, then you need to educate them on realistic and achievable goals for your treatments. Also, this can help you better understand the client's feelings about their own skin, what they consider their problem areas to be, and what treatments and products would offer them the best results.
  2. Are you using Glycolic Acid, Retinols, Retin-A, Accutane or topical prescription medication? This question covers several potential associated risks. First, you do not want to wax the skin if the client has been on retinoids within the last 72 hours. Using certain topical medications (like antibiotics) can make the skin more sensitive and more inflammatory. Your choice of modalities, such as microdermabrasion or other mechanical devices, can differ depending on the client's susceptibility to react based on their use of the topical prescriptions. A pre-recommendation for treatments like chemical peels is to refrain from using active ingredients at least 48 hours in advance of treatment so it is necessary to know what products they are currently using and the last time they applied them. Accutane users will have extremely sensitive skin and should not receive any type of exfoliation while they are on this medication. They may even need to refrain from doing facials for at least six months. 
  3. Are you taking any medications? Medications, especially antibiotics, can make the skin hypersensitive. Knowing the client's medication use can also be a good insight into the background history of the client. For instance, someone with a history of a nervous disorder may not be a candidate for a chemical peel as emotional stability is important when recovering from a deep peel. 
  4. Do you have any medical conditions, including but not limited to: skin disease, hepatitis, HIV/AIDS, herpes, seizure disorder, active infections, heart condition, diabetes, rash, cancer, drug/alcohol, lymph edema, high/low blood pressure, depression? Medical conditions are important in measuring the capacity for wound healing. Many intensive clinical skin care treatments are based on the principle of contained wounding of the skin to boost collagen production. Wound management and the healing process will vary depending on current medical conditions. For instance, a diabetic's skin will have a longer wound healing process and this will need to be kept in mind when deciding upon treatment options. Many treatments are contraindicated for people with certain conditions. You would not perform a TCA peel on someone with a heart condition because the heart rate can go up, due to the body's natural response to the heat caused by the acid. 
  5. Do you have any allergies? People can be allergic to certain ingredients in products and certain tools used in the treatment room. For instance, salicylic acid is an active metabolite of aspirin and clients with an allergy to aspirin should avoid the use of this peel. Latex allergies can be seen a lot with clients; therefore, you want to be sure to use latex-free gloves in the treatment room to ensure no reaction takes place. 
  6. What skin care products are you currently using? Knowing the brand of products your client is using is important not only for your own retail recommendations but for an insight into their buying habits and current active ingredient use. As an aesthetician, it is your main goal to perform an educated consult with the client and to do this it is necessary to know what they are currently putting on their skin. It will help you to figure out where they are on the consumer scale, to educate them on what they are using on their skin, whether or not it is a good fit for their skin condition, and how to proceed with their home care. Optimal results are only achieved through treatment that coincides with an effective home care regime. It also helps your recommendation to understand what they like or do not like about their current products to enable you to recommend a more suitable one based on their preferences and needs. 
  7. What is your level of sun exposure? A lot of clinical treatments require your client to wear sunscreen and limit sun exposure. Sun is the skin's worst enemy and unfortunately most aging skin conditions are caused by the sun's harmful rays. If the client is going to be dedicated to a skin care plan to address the signs of aging, they need to be protecting themselves from the root cause. It is counterproductive to place a client on an aging skin or hyperpigmentation treatment regime if they are constantly in the sun without protection. Also, laser treatments and chemical peels especially require no pre- or post-sun exposure because the skin's sensitivity to sunlight is increased. It is necessary to warn your clients about the necessary precautions and potential complications. 
  8. What is your exfoliation history? Most people are not exfoliating properly or enough but it is important to know the frequency and type of exfoliation treatments they are receiving in clinic or doing at home. Knowing their exfoliation history lets the aesthetician know how fast or slow their cell turnover rate is, what types of exfoliation methods they are doing and whether those methods are the best choice for their skin.

While we have all been to the doctor's office and grumbled when we were handed numerous sheets of forms to fill out, we also did so on the understanding that the information is a pertinent part of successful patient care. Implementing client intake forms in your business will give your clients a feeling of safety and security and establish you in their minds as a professional they can trust.

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