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Skin Consultation Form
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Skin Consultation Form
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Skin Consultation form
Full Name
Last Name
Mobile
Email
Address Line1
Address Line2
City
State / Country
Date of Birth
Occupation
Are you currently seeing your doctor for any medical conditions?
Yes
No
Are you taking any medication?
Yes
No
If yes please List
Are you taking any natural / holistic supplements? If yes please give details below
Do you have any allergies (including salicylic / aspirin, nut or latex)?
Yes
No
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
Please let us know if Skin Cancer has been in your immediate family line - i.e Mother / Father / Siblings etc ..
In the past have you had a skin allergy / reaction after a treatment? Please give details below of reaction.
Have you been under the treatment / supervision of a Dermatologist? Please give details below.
Do you use any topical medications? e.g. Hydrocortisone Cream etc . .
Yes
No
Do you have eczema / psoriasis?
Yes
No
Have you undergone any form of Cosmetic procedure(s) the past or planning on any in the near future? Please give details below.
Are you prone to cold-sores / lip herpes?
Yes
No
Do you have any other allergies/ intolerances to cosmetic ingredients
Yes
No
Could you be pregnant, planning a pregnancy or breast feeding? Please give details below
Do you or have you in the past sunbathe or use sunbeds regularly?
Yes
No
If answered yes to the above question how frequently did you or do you use them?
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? *note if having a Skin Treatment these must be removed prior to commencement of treatment
Do you undertake any exercise? If yes please let us know how many times per week & type of exercise.
Do you smoke or live with anyone who smokes?
Smokes
Lives with someone that smokes
No
What is your daily intake of water? (in litres)
If you wear makeup, how does it 'sit' on your face during the day / night?
How does your skin feel at different times throughout the day? (e.g. - Oily / Tight / Dry / Inflammed etc ..)
What is your current skincare regime? Please list all products you're currently using on your skin and break them into morning and evening routine.
List the main areas of concern on your face: Highlighting the top skin priority that you wish to see an improvement on.
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
Have you undergone any cosmetic procedures?
Yes
No
If yes please list
Are you planning a sun holiday in the next 6 weeks?
Yes
No
Do you wear contact lenses?
Yes
No
Do you undertake any exercise?
Yes
No
What is your current skincare regime? Please list all products your currently use on your skin
What outcome do you want from your consultation today? I.e. Home-Care Routine / In-House Treatment(s) recommendations - please state specifically below.
Are you interested in
Facials
Peels
Micro-needling
LED Light Treatment
Other
If answered other please state below -
Send
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
