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Skin assessment form
First name
Surname
Email address
Telephone number
What changes are you hoping to see in your skin?
Are you prone to any of the following?
Psoriasis
Eczema
Keloid Scarring
Rosacea
Herpes Simples (coldsores)
None
If yes, please provide details:
Please indicate if you have or have had any of the following?
Pregnant or breastfeeding
Diabetes
Epilepsy
Cardiac Irregularities
Pacemaker
Metal pins/plates in the body
Radiotherapy
Chemotherapy
Moles or sunspots removed
History of thrombosis/embolism
Circulatory disorders
Multiple sclerosis
Porphyria
Thyroid irregularities
None
Any other medical conditions? Please specify
Any known allergies?
Have you been treated with any of the following?
HRT (Hormone Replacement Therapy)
Bioidentical HRT
Contraceptive pill
Topical corticosteroids yes
Oral corticosteroids
Topical Antibiotics
Oral Antibiotics
Roaccutane
Acne medication (eg Benzoyl peroxide, Azelaic acid, Alpha hydroxy acids, antibiotics)
Blood thinning medication (eg warfarin)
Any other medication? Please specify
Please indicate if you are having or have had any of the following
Micro Needling
Laser Treatments
IPL
Mircoder
Electrolysis
Facial Waxing
Botox
Filler
Chemical peels
If yes please give the dates of the last treatment
Any other skin treatments not on the list please specify
Do you have concerns with any of the following?
Pigmentation
Acne scarring
Uneven texture
Fine lines and wrinkles
Enlarged pores
Loss of facial contours
Oily skin
Dilated capillaries
Lax or sagging skin
Acne/breakouts
Redness
Dark circles under eyes
Puffiness under eyes
None of the above
If yes to any of the above, can you provide any more details
What skin type do you think you have?
Dry
Dehydrated
Oily
Combination
Normal
Add any details regarding your skin type here
Tell us which vitamins/supplements you take
Are any of these for your skin?
Yes
No
How much water do you drink per day?
Less then 2 glasses
2-4 glasses
Over 2 litres
How many caffeinated drinks do you have per day?
How many units of alcohol do you drink per week?
None
1-3
4-5
More than 5 units per week
Only 1-3 per month
Do you suffer with any of the following?
IBS
Bloating
Digestion problems
Food intolerances
If yes to any of the above, please give more information
Do you take any probiotics?
Yes
No
Do you travel regularly? eg over 4 times per year
Yes
No
In as much detail please provide an average day for your diet
Please tell us your current skin care routine and include which brands you use for each product
Are you claustrophbic?
Yes
No
Do you wear contact lenses?
Yes
No
Please tell us any health conditions that could affect your treatment?
What are your skin goals?
I confirm that all the above information provided is to the best of my knowledge
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