Online Skin Consultation
Please fill this form out in as much detail as possible. The form will help to paint a picture of what could be going on with your skin, and will enable me to make the right recommendations as a result. Please let me know when you have sent the form!
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Date
-
Month
-
Day
Year
Date
Occupation
Age
GP Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are you suffering from any of the following?
Infectious diseases Eg. Impetigo
Boils
Ringworm
Coldsore (herpes simplex)
Chicken pox (chicken pox)
Warts
Damaged skin Eg. Sunburn
Infectious eye problems Eg. Conjunctivitis
Scabies (or any other infestations)
Please tick if any of the following apply to you
Diabetes
Epilepsy
Cancer
High or low blood pressure
Pregnancy
Skin disorder
Recent operation
Heart/cardiac disorder
Thrombosis/Phlebitis (blood clots)
Pacemaker or internal metal pins
History of skin cancer
Thyroid problem
Currently receiving medical treatment
Any tumours, abnormal swelling or lymph oedema
Recently had Botox/Collagen/Injectables
Contraception/hormonal substitute
Tattoo/semi permanent make up in the area
If yes, please provide notes here
Any medication?
In the last 9 months, have you undergone any surgery? If yes, please specify below.
Any health problems, past and present?
List of any medication and supplements you are currently taking
Allergies?
Life style - sedentary? Exercise regime? Stress levels? How much water?
Do you follow a restricted diet - please give details
How much alcohol do you consume per week?
Do you smoke? If yes, how long for?
How many caffeinated beverages daily?
What does a typical days food look like for you? Please list brands and include all snacks and drinks. As much information as possible.
What does a typical day look like for you? What do you do as soon as you wake up? Do you work from home or in an office? Do you get outdoors for fresh air and sunlight daily?
Current skincare routine including products?
Have you ever had a chemical peel, laser, microdermabrasion or any resurfacing treatments? When?
Have you used Accutane, Retin A, Renova or any other prescription skin products in the three months?
Are you currently using any products that contain Glycolic acid, Lactic acid, any Hydroxy acid product, Vitamim A derivatives and any exfoliation scrubs? If yes, which ones and by which brand?
Current complaint
Breakouts
Acne
Blackheads/whiteheads
Excessive oil/shine
Rosacea
Broken capillaries
Redness
Uneven skin tone
Sun damage/pigmentation
Wrinkles/fine lines
Dull/dry skin
Flaky skin
Dehydrated
Open pores
What age did these problems occur?
Are your current skin problems getting more pronounced?
Yes
No
Have you received treatment for this problem before? If yes, when and what method?
Do you ever experience these conditions with your skin?
Flakiness
Tightness
Obvious dryness
Do you burn easily in moderate sunlight?
Do you blush easily when nervous?
Do you have a tendency to redness?
How does your skin feel on a daily basis? Normal? Oily? Dry?
Are you prone to cold sores?
Do you ever expierence a burning/itching sensation on your skin?
Have you ever had a reaction to any of the following
Cosmetics
Medicine
Iodine
Pollen
Food
Hydroxy acids
Animals
Fragrance
Sunscreen
Other
Are you currently having or due your period?
Yes
No
N/A
What are your skincare goals? How can I help you?
Signature
Take Photo
Take Photo
Take Photo
Email
example@example.com
Submit
Should be Empty: