| *Name |
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| *Date of Birth (DD/MM/YYYY) |
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| *Address |
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| *Email |
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| Telephone Number: |
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| Please describe your skin concerns and what you want to acheive |
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MEDICAL HISTORY |
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*Do you suffer from any allergies?
|
Yes
No
|
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*Have you a history of severe allergic reaction?
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Yes
No
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*Are you currently taking any medication?
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Yes
No
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*Do you suffer from stress/anxiety attacks?
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Yes
No
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*Are you taking HRT - hormone replacement therapy?
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Yes
No
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*Are you pregnant/trying to become pregnant or breast-feeding?
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Yes
No
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*Do you suffer from asthma or any respiratory disorders?
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Yes
No
|
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*Are you diabetic?
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Yes
No
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*Do you suffer from any type of autoimmune disease e.g. Lupus?
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Yes
No
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*Do you suffer from any active skin conditions e.g. psoriasis, eczema?
|
Yes
No
|
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*Do you suffer from urticaria or have a history of skin rashes?
|
Yes
No
|
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*Do you suffer from herpes simplex virus i.e. cold sores?
|
Yes
No
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| If you answered YES to any questions please give further information or if have any other relevant medical history of note including operations and treatments please specify |
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SKIN HISTORY |
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*Do you currently use any retinol/vitamin A based products?
|
Yes
No
|
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*Are you using any glycolic based products?
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Yes
No
|
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*Have you used Accutane (Roaccutane) within the last 6 months?
|
Yes
No
|
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*Are you sensitive to alcohol based skin products?
|
Yes
No
|
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*Have you ever had a skin reaction from any skin products? |
Yes
No
|
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*Do you suffer with hyper or hypo pigmentation changes of the skin (Loss of pigment)? |
Yes
No
|
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*Do you have a history of keloid/hypertrophic scarring ? |
Yes
No
|
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*Have you recently undergone any facial laser treatments? |
Yes
No
|
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*Have you ever had any form of laser treatment? |
Yes
No
|
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*Have you recently had any facial waxing/depilatories/electrolysis? |
Yes
No
|
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*Have you recently used a sunbed or sunbathed? |
Yes
No
|
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*Do you use fake sun tan on your face? |
Yes
No
|
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*Do you tan easily? |
Yes
No
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| If you answered YES to any of the previous questions please give further information |
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| *Describe you daily skin care routine |
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| What skin care products do you normally use? |
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| I confirm that I have completed my medical history in full and understand that failure to declare all of my medical history details may result in failure of the treatment/products and increase the risk of possible complications |
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