Skin Health & Lifestyle Assessment

Skin Health & Lifestyle Assessment
Name *

First Name Last Name
Date of Birth *

Day Month Year
Date
Address *

Address Line 1

Address Line 2

Town/Village County

Post Code
Phone Number *
Email *
example@example.com
Occupation
Emergency Contact
Emergency Contact Telephone Number
How did you hear about me? *

Facebook Instagram Online Search Referral
If referred, by who?
Your Medical History
Are you currently under the care of a physician? *

YES NO
Have you ever been diagnosed with any of the following health conditions? *

Cancer/ Systemic disease High Blood Pressure Type 1 Diabetes Heart Conditions Type 2 Diabetes Stroke Arthritis Hepatitis Kidney Disorder Liver Disorder Digestive Problems Migraine Auto-immune Disorder Asthma Epilepsy/Seizures Cold sores/blisters Lupus Depression/Anxiety Headaches/ Migraines Eczema Psoriasis Dermatitis Rosacea Acne History of Anaphylaxis Diabetes Haemophilia Blood Disorders Recent Virus (within the last 2-4 weeks) History of Skin Cancer Are you Pregnant or Nursing/ Receiving Fertility Treatment Hormonal Imbalance (PCOS/Endometerosis/Fibroids/Cysts) Taken Acctutane in the last 6 months Glucoma Chest Pain/Shortness of Breath Allergies History of Keloid Scarring Other
Are you taking prescribed medication including the Contaceptive Pill/ HRT – State brand
Are you taking any non prescription medication including Vitamin supplements, St Johns Wort, Probiotics etc?
Do you have a history of regular or long term antibiotic use?

YES NO
Do you have any allergies? *

Asprin Latex Fruits Shellfish Lidocaine Fragrance/Essential Oils Nuts Dairy Sunscreen Pollen Other
Have you ever experienced claustrophobia?

YES NO
Please rate your normal stress level.

Low Medium High None
How much water do you drink per day?

None 1-2 litres More than 3 litres
How would you describe you diet?

Very Healthy Mostly Healthy Very Unhealthy
Do you regularly consume foods/drinks containing artificial sweeteners?

YES NO
Do you eat processed and/or convenience foods more than 2 times a week?

YES NO
Do you consume whey protein drinks/bars on a regular basis?

YES NO
Do you have any digestive health problems including; constipation, gas, diarrhoea, IBS, reflux, bad breath?

YES NO
Do you have thinning hair, brows, lashes?

YES NO
Have you ever received botox or fillers? If so, where on the face and when?
Have you had any form of Semi Permanent Makeup, If so when was your last treatment?
What are your skin concerns/ reasons for seeking treatment?
Have you had any previous treatment for this, if yes please give a brief outline of the treatments you have had.
Which best describes your skin?

I. Pale white skin, blue/green eyes, blond/red hair - Always burns, does not tan. II. Fair skin, blue eyes - Burns easily, tans poorly. III. Darker white skin - Tans after initial burn. IV. Light brown skin - Burns minimally, tans easily. V. Brown skin - Rarely burns, tans darkly easily. VI. Dark brown or black skin - Never burns, always tans darkly.
How would you describe your skin?

Normal (no visible blemishes, fine pores, smooth texture) Sensitive (reactive to fragrance, often irritated) Combination (oily and dry patches, oily T-zone, hormonal breakouts) Oily (enlarged pores, excessive oil) Acne (cystic or nodules) Dry (dull, visible lines and wrinkles, feels tight)
What skin care products do you use on a regular basis?

Soap Cleanser Toner Serum Mask Exfoliant (physical or chemical) Eye Cream SPF Moisturiser Vitamin A (Retinol)
Skincare brands used
How many times a week do you exfoliate and/or use a mechanical cleansing brush?
Do you experience routine breakouts or acne?

YES NO
Have you been diagnosed with eczema, psoriasis or rosacea?

YES NO
Have you used any of these facial hair removal methods in the last 14 days?

Waxing/sugaring Threading Laser/Electrolysis Depilatory Cream Facial Bleaching
Have you had any of the following treatments in the last 6 weeks?

Skin Peel Microdermabrasion Micro-needling/ Mesotherapy Sunbed or Sun Exposure
Do you currently use:

Use Retinol in skincare Retin-A (prescribed) Prescribed topical cream such as Duac, Steroid cream, Anti- Histamine
Please specify which product or type, if you answered YES to the question above.
Declarations & Acknowledgements

Appointments and Cancellations

I acknowledge that I must adhere to Charlotte Rye Aesthetics policies.

I understand that cancellations must be made with at least 48 hours notice.

I acknowledge that ANY No-Show will result in the loss of a single treatment from a pre paid course or 100% of the total service cost.

I understand that if I arrive late for my appointment it may be subject to cancellation or to a reduced treatment time and I will be responsible in accordance with the “No-Show” policy.

After Treatment Skincare

I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity.

I agree to follow the after care given to me and acknowledge that failure to do so could result in an adverse reaction and have a negative effect on the results of my treatment.

I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions.

I acknowledge that I must use a skin protection product SPF 50 after my treatment and for a minnimum of 72 hours post treatment. If I fail to use a minimal sunscreen (SPF 50), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure. It is STRONGLY advised that you use a broard spectrum protection product daily as part of your skincare routine.

I acknowledge that this treatment is strictly elective cosmetic procedure and no medical claims have been expressed or implied. I understand that results may vary and cannot be guaranteed.

I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are not part of the recommended take-home regimen for 1 week following treatment.

Consent

I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments

I release Charlotte Rye of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.
Date *

Day Month Year
Date
Signature *

Clear
Treatment Notes
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm

Skin Health & Lifestyle Assessment

Your Medical History

Declarations & Acknowledgements

Appointments and Cancellations

After Treatment Skincare

Consent