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Skin Consultation Form
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Skin Consultation Form
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Skin Consultation form
Full Name
Mobile
Date of Birth
Email
Address
Occupation
Sex
Are you currently seeing your doctor for any medical conditions?
Yes
No
Are you taking any medication?
Yes
No
If yes please List
Do you have any allergies (including salicylic / aspirin, nut or latex)?
Yes
No
Do you have any of the following?
Lupus
Diabetes
Hormonal Imbalance
Peacemaker
Broken Veins
High Blood Pressure
Low Blood Pressure
What is your current level of stress? (Low 1 – High 10)
Have you been diagnosed with HIV positive, AIDS or Hepatitis C?
Yes
No
Have you or any members of your family had cancer or skin cancer?
Yes
No
Have you ever had chemotherapy / radiotherapy?
Yes
No
Have you had a skin allergy/ reaction after a treatment?
Yes
No
Have you ever seen a dermatologist?
Yes
No
Do you use any topical medications?
Yes
No
Do you have eczema / psoriasis?
Yes
No
Have you undergone any cosmetic procedures?
Yes
No
Do you have any other allergies/ intolerances to cosmetic ingredients
Yes
No
If yes please list
Are you prone to cold-sores / lip herpes?
Yes
No
Could you be pregnant, planning a pregnancy or breast feeding?
Yes
No
Do you sunbathe or use sunbeds?
Yes
No
Are you planning a sun holiday in the next 6 weeks?
Yes
No
Do you suffer from claustrophobia?
Yes
No
Do you suffer from asthma?
Yes
No
Do you wear contact lenses?
Yes
No
Do you undertake any exercise?
Yes
No
Do you smoke or live with anyone who smokes?
Yes
No
What is your daily water intake?
What is your current skincare regime? Please list all products your currently use on your skin
List the main areas of concern on your face
Highlighting your top skin priority that you wish to see an improvement on
What outcome do you want from your consultation today?
Are you interested in
Facials
Peels
Micro-needling
Send
