CONFIDENTIAL SKIN HEALTH QUESTIONNAIRE

Take Photo - Please take a clear, well lit portrait picture of your face, without make up Please look straight at the camera not at the screen
SKIN HEALTH QUESTIONNAIRE

Please complete this form detailing your main concerns and current skincare routine. Online video Skincare Consultations take place by WhatsApp video (25` minutes) In clinic face-to-face Skincare Consultation & New Client’s First Facial (which is the consultation followed by an appropriate facial treatment 1.5 hours) can be booked online at DianeNivern.com or call us on 01617961169
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityCounty

Post Code
MOBILE*
Consultations via WhatsApp video call Please add 0161 796 1169 to your WhatsApp contacts Diane Nivern Clinic
EMAIL ADDRESS*
DATE OF BIRTH*

DayMonthYear
Date
Age at time of consultation*
How did you hear about us?*
Web search what did you search for ? / Recommendation from who? / Instagram / Facebook / other?
OCCUPATION*
This gives me insight into how your skin may be affected by your occupation. Do you spend a lot of time at a computer?
LIST OF ALL ALLERGIES*
Are you planning for a special occasion ?*
Such as a wedding or birthday - if so when is the event?
What would you like to achieve by seeking professional skincare treatments & advice?*
Please give me an idea of what help you’re looking for
NORMALDRY/DEHYDRATEDOILY / COMBINATIONACNE/ACNE PRONEROSACEASENSITIVE / REACTIVE
I'd like you to feel and stroke your face - does it feel smooth, rough, patchy, puffy, oily, hot, tight or flaky anywhere?*

Which of these concerns you and how much?*

Rows	Very much	Somewhat	Not Much	Not at all
Wrinkles, Lines, Ageing Skin
Acne / Spots
Blackheads / Bumps under skin
Pigmentation (brown or red marks)
Scarring / Pitting
Rosacea / Redness
Oily Skin
Dry / Flaky Skin
Sensitive / Reactive Skin
Improve skin texture
Dullness / Lack of radiance
Thin or Sagging skin
Droopy eyelids / Eyebags
Skin Tags / Cherry Angiomas

Skincare Products onlyBespoke FacialsPeels (superficial to medium depth)MicroneedlingInjectable TreatmentsPlasma soft surgeryOther
MaleFemale
Wrinkle relaxing injections (botox)?Dermal Fillers for lipsDermal Fillers for facial contours / lines / cheeks / jawlineSkinboosting for collagen stimulation skin quality, hydration, firmness, radiance?Eyelid lifting / Eye bag smoothingBlemish removal / skin tags, cherry angiomas, age spotsFacial skincare treatments
How do you feel about your skin & appearance?*
ACNEDEPRESSION / ANXIETYSKIN DISEASECOLD SORESDIABETESCANCERECZEMA / DERMATITISOther
What products or treatments have you tried before? What was the outcome*
Where you happy with results, any reactions or comments?
Type 1: ‘No Wrinkles’ Early skin-aging Mild pigment changes Minimal wrinkles No ‘age spots’Type 2: ‘Wrinkles in Motion’ Patient age: 30s to 40s Early to moderate visible ageing, Appearance of lines only when face moves, Early brown ‘age spots’, Skin pores more prominent, Early changes in skin textureType 3: ‘Wrinkles at Rest’, Advanced visible ageing, Prominent brown pigmentation, Visible brown ‘age spots’, Prominent, visible thread veins, Wrinkles present with face at restType 4: ‘Only Wrinkles’, Severe visible ageing, Wrinkles everywhere, at rest or moving Yellow-gray skin colour Prior skin cancers Pre-cancerous skin changes
Pale, freckles, blond / red hair, blue / green (I)Fair, freckles, blond, blue eyes (II)Fair/ beige, dark blond / light brown, hazel (III)Olive, light brown, brown hair brown eyes (IV)Dark brown, brown / black hair, brown eyes(V)Black skin, black hair, brown eyes (VI)
DO YOU / HAVE YOU SMOKED or VAPED?*
Do you have any significant health / medical history?*
Medication including Pill, Vitamins or supplements*
What medication?
ARE YOU PREGNANT? TRYING TO GET PREGNANT? HRT? IVF?*
YOUR CURRENT LEVEL OF STRESS: (1 least to 10 most)*
YOUR NORMAL LEVEL OF STRESS: (1 least to 10 most)*
Please describe ethnic background of both parents*
This helps me to understand your skin's characteristics for suitable treatments & products
Do you / have you exposed your face to SUN or TANNING BEDS?*
ARE YOU PLANNING A HOLIDAY WITH SUN EXPOSURE SOON?
Regularly eat fruit & veg?Regularly eat meat / fish?Milk / Cheese?Vegetarian / Vegan?Take Aways / Ready meals?
How much alcohol do you drink per week?*
UNDER A LITREA LITREOVER A LITRE
DERMATOLOGISTPLASTIC SURGEONAESTHETICIANFACIAL HAIR REMOVAL laser / wax / threading?Other
Dedicated / Multi step programme day & nightCould manage a simple day & night routineOften forget to take make up offOther
WHAT SKINCARE PRODUCTS / BRANDS ARE YOU CURRENTLY USING? Please list *
Please list cleansers / face wash / serums / treatment products/ moisturisers /sunscreens used - Brand & product name is helpful
Have you ever experienced an allergic reaction to a topical skincare product or previous procedure? Please provide details
DO YOU USE A DAILY SUNSCREEN PROTECTION PRODUCT? WHICH FACTOR?*
DO YOU EXERCISE? What type of exercise & how often?
Is there anything else you’d like advice or help with today?
Thank you for completing my questionaire.

Your answers will help me to understand your skin's needs to design the most appropriate in-clinic treatments with supporting home skincare routine.

I look forward to meeting you soon

Diane Nivern
SIGNATURE:*

Clear
The information Have supplied
DATE:*

DayMonthYear
Date
Preparing for your appointment;

To faciltate an accurate analysis of your skin we would appreciate it if on the night before your appointment you cleansed your skin as usual but don't apply any of your skincare products

On the day of the appointment if you can attaend free of any make up or skincare products such as SPF this will help us to analyse your true skin type.

Appointment policy

When you proceed to book your appointment you will be asked to pay a non-refundable booking fee to hold your consultation appointment slot

The fee is redeemable against the cost of you facial treatment or purchase of our recommended products over £130 or from future treatments.
This booking fee is retained by Diane Nivern Clinic Ltd if you don't attend your booked consultation or cancel / reschedule with less than two days notice -

If you need to reschedule the appointment the booking fee will be transferred to the next appointment - TWO days notice required )
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