Skin Health & Lifestyle Assessment

Skin Health & Lifestyle Assessment
Name*

First NameLast Name
Date of Birth *

DayMonthYear
Date
Address*

Address Line 1

Address Line 2

Town/VillageCounty

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

FacebookInstagramOnline SearchReferral
If referred, by who?
Your Medical History
Are you currently under the care of a physician?*

YESNO
Have you ever been diagnosed with any of the following health conditions?*

Cancer/ Systemic diseaseHigh Blood PressureType 1 DiabetesHeart ConditionsType 2 DiabetesStrokeArthritisHepatitisKidney DisorderLiver DisorderDigestive ProblemsMigraineAuto-immune DisorderAsthmaEpilepsy/SeizuresCold sores/blistersLupusDepression/AnxietyHeadaches/ MigrainesEczemaPsoriasisDermatitisRosaceaAcneHistory of AnaphylaxisDiabetesHaemophiliaBlood DisordersRecent Virus (within the last 2-4 weeks)History of Skin CancerAre you Pregnant or Nursing/ Receiving Fertility TreatmentHormonal Imbalance (PCOS/Endometerosis/Fibroids/Cysts)Taken Acctutane in the last 6 monthsGlucomaChest Pain/Shortness of BreathAllergiesHistory of Keloid ScarringOther
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?

YESNO
Do you have any allergies?*

AsprinLatexFruitsShellfishLidocaineFragrance/Essential OilsNutsDairySunscreenPollenOther
Have you ever experienced claustrophobia?

YESNO
Please rate your normal stress level.

LowMediumHighNone
How much water do you drink per day?

None1-2 litresMore than 3 litres
How would you describe you diet?

Very HealthyMostly HealthyVery Unhealthy
Do you regularly consume foods/drinks containing artificial sweeteners?

YESNO
Do you eat processed and/or convenience foods more than 2 times a week?

YESNO
Do you consume whey protein drinks/bars on a regular basis?

YESNO
Do you have any digestive health problems including; constipation, gas, diarrhoea, IBS, reflux, bad breath?

YESNO
Do you have thinning hair, brows, lashes?

YESNO
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?

SoapCleanserTonerSerumMaskExfoliant (physical or chemical)Eye CreamSPFMoisturiserVitamin 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?

YESNO
Have you been diagnosed with eczema, psoriasis or rosacea?

YESNO
Have you used any of these facial hair removal methods in the last 14 days?

Waxing/sugaringThreadingLaser/ElectrolysisDepilatory CreamFacial Bleaching
Have you had any of the following treatments in the last 6 weeks?

Skin PeelMicrodermabrasionMicro-needling/ MesotherapySunbedor Sun Exposure
Do you currently use:

Use Retinol in skincareRetin-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*

DayMonthYear
Date
Signature*

Clear
I grant permission for Charlotte Rye Aesthetics to use photos taken of results and treatments for social media purposes (e.g Instagram, Facebook and website use).
Treatment Notes
Should be Empty:

Skin Health & Lifestyle Assessment

Your Medical History

Declarations & Acknowledgements

Appointments and Cancellations

After Treatment Skincare

Consent