Hello!

Ali Rockwood

Esthetician

CA License #: Z96784

We’re here to help with your skin!

In my career as an esthetician I’ve been fortunate to work with a widely diverse clientele and to have learned from, worked beside, and in some instances taught countless brilliant, highly skilled, knowledgeable artists and technicians in the skin care industry.

Over the years many of these incredible people have become My Estie Besties.

Fill out the questionnaire below and join us!

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Thank you for your response. ✨

Name

City, State, Zip

Date of Birth (year) (YYYY-MM-DD)

Health History

Please answer as thoroughly and honestly as possible. We do not judge your lifestyle or choices!

Do you smoke cigarettes?

Yes No

Are you pregnant or trying to become pregnant?

Yes No

Do you suffer from seasonal allergies? (grass, ragweed, tree pollen)

Yes No

Do you suffer from contact allergies? (rubber, latex, nickel, aspirin)

Yes No

Do you have any food allergies? (Fish, shellfish, nuts, eggs, fruit, etc.)

Yes No

Do you use blood thinners?

Yes No

Do you use hormone therapy or hormonal birth control?

Yes No

In the past 12 months, have you been treated for:

Cancer?

Yes No

Acne?

Yes No If yes, please spedify treatment as thoroughly as possible

High blood pressure?

Yes No

Diabetes?

Yes No

Any skin disease or disorder?

Yes No

Cold Sores or fever blisters?

Yes No If yes, when was last outbreak?

Personal Information

What is your current level of stress?

(1 Low- 5 High)

1- Low, totally chillin, sometimes I get bored 2-Low with easy responsibilities, not bored 3- Balancing life and for the most part getting it right. I feel like I'm mostly in control of things. 4- Lightly stressed- balancing life is a struggle on some days but I usually get a chance to recharge, just not often enough 5- Stressed out, finding balance is a struggle on most days. I feel like I'm not in control of my life and need to make a change

What is your normal level of stress?

(1 Low- 5 High)

Do you use Vitamins or Supplements?

Yes No

Do you use tanning beds or “lay out” to get tan?

Yes No

How much water do you drink per day, on average?

1-3 glasses 4-6 glasses 7 glasses or more

How many caffeinated beverages do you consume per day, on average?

1-3 caffeinated beverages 4-6 caffeinated beverages 7 or more caffeinated beverages

How many soft drinks or sweetened beverages do you consume per day, on average?

1-3 caffeinated beverages 4-6 caffeinated beverages 7 or more caffeinated beverages

How much exercise do you get each week?

Have you ever been seen by a Dermatologist or Esthetician?

Yes No

Do you ever experience itching or burning from skin care products?

Yes No

Does your skin ever feel dry or “tight” after cleansing (before moisturizer)?

Yes No

Do you ever experience an “oily shine?”

Personal Information

When in the sun do you:

Product Information

What products are you currently using? How often? Answer frequency only for those that apply

How do you feel about your skin today?

Pretty good Not so great

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Thank you for your response. ✨

Check the status of a CA provider’s Licensure here: https://search.dca.ca.gov/