Language
English (UK)
ONLINE SKIN CONSULTATION
AOIFE GARRIHY BEAUTY
PERSONAL DETAILS
Name
First Name
Last Name
DOB
/
Month
/
Day
Year
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone number
MEDICAL QUESTIONNAIRE
Are you currently taking any medication prescribed by a GP or any other practitioners? If yes, please list the medication below;
Are you currently taking any medication containing Vitamin A?
Are you currently taking any vitamins/supplements? If yes, please list them below;
Are you currently planning pregnancy, pregnant or breastfeeding? If yes, please provide further information;
Are you attending a GP, or any other practitioner for any other conditions? Is yes, please provide further information;
Do you have any allergies?
SKIN QUESTIONNAIRE
What is your skin type?
Dry (Tight, dull, flaky)
Oily (Shiney, blackheads, large pores)
Combination (Dry cheeks, oily T-zone)
Normal (Balanced and smooth)
Tell me what are your main concerns?
Lines and wrinkles
Pigmentation
Dehydration
Breakouts/congestion/acne
Redness/rosacea/sensitivity
Do you use sunbeds?
Do you smoke?
On a scale of 1-10, how sensitive would you rate your skin?
Do you wear SPF? Is so, please state what brand, what factor, and how often you reapply;
Are you prone to, or do you have any of the following?
Eczema
Psoriasis
Roscaea
Herpes Simplex
Do you get any of the following?
Commedones/Blackheads
Pustules/Whiteheads
Cystic Acne
Ocassional Spots
Hormonal Breakouts
No breakouts
Are you happy with your current skincare, and are you seeing results?
If you are not happy with your skin at the moment, what are you unhappy with?
If you are happy with your skin at the moment, what are you happy with?
If you wear make up on a regular basis, what brands do you wear?
Please tell us about your diet. In terms of whether you eat red meat, oily fish, drink water, etc.
Do you have any health concerns, or auto immune diseases?
On a scale of 1-10, what is your current stress level?
CURRENT SKIN ROUTINE
Please give as much detail as possible. If you do not use any of the following, leave blank.
Eye Make-Up Remover
Cleansers
Toners
Exfoliants
Serums/Masks
Moisturisers
Do you use these products every am & pm? Is there any additional products/info you would like to give us in relation to your skin routine?
Finally, what are your skincare goals, and main concerns? Let us know how you would like us to help you on your journey to Healthy Skin;
SKIN IMAGES
Please upload some CLEAR-MAKE UP FREE images of your skin. Make sure the lighting is good, and photos are clear.
Please upload photo of your skin
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