AQ Hair complex+ Consultation Form

AQ Hair complex+ Consultation Form

Client Personal Information
Client Name

First NameLast Name
Date of birth

DayMonthYear
Date of birth
Address

Street Address

Street Address Line 2

CityCounty

Post Code
Home Phone Number
Phone number
Mobile Phone Number
Mobile Phone number
Email
example@example.com
Emergency Contact
Name Emergency contact name and mobile no. Emergency Mobile no
Doctor's Name
Doctor's Name
Doctor's Address

Street Address

Street Address Line 2

CityCounty

Post Code
Doctor's Tel Number
Dr Mobile Phone number
What is your ethnic group?
Ethnic group
Do you wear contact lenses?

NoYes
CLIENT LIFESTYLE ASSESSMENT
What is you occupation?
Occupation
Do you work in a centrally heated or air conditioned environment?

NoYes
Are you city based?

NoYes
Do you work mainly outdoors?

NoYes
Do you have children and if so how old are they?
Yes No
I have No of children children and the age(s) (is)arechildren ages.
Do you smoke cigarettes?
Yes No
How may do you smoke per day?No of children
What is your sun history?
Sun history
When in the sun do you?

Burn easily and never tanBurn easily and then tanTan and rarely burnNever burn in the sun
Do you use sunbeds? Yes No
How often?No of children
Do you wear sunscreen daily? Yes No
If so, what SPF Factor do you use?No of children
Does you sunscreen have a PPD Index?

NoYes
Do you use a topical antioxidant?

NoYes
When was your last exposure to intense sunlight?
Intense sunlight
Are you planning an overseas holiday in the next 4 -6weeks?

NoYes
Have you ever had skin cancer?

NoYes
Do you have any marks or blemishes on your skin that have changed or seem not to be able to heal?

NoYes
CLIENT MEDICAL HISTORY FORM

Answer the following questions with a for YES ora for NO and give further details where required.

	Yes	No
Are you or might you be pregnant?
Are you trying to become pregnant?
Are you breast feeding?
Are you currently feeling well?
Have you had any issues of ill health, even the most minor, in the last 4 weeks?
Are you suffering from, or have you ever been diagnosed with any of the following conditions?
Diabetes?
High / low blood pressure?
Epilepsy?
Heart disease/ heart condition?
Anaphylaxis?
Hay fever?
Hepatitis / HIV?
Rheumatoid Arthritis?
Lupus?
Haemophilia?
Psoriasis?
Eczema?
Anaemia?
Alopecia?
Cancer?
Polycystic ovarian Syndrome?
Keloid or hypertrophic scarring?
Anxiety or Depression?
Mental health issues?
Thyroid problems?
Asthma / lung disease?
Fainting / dizziness/ vertigo?
Kidney/ liver problems?
Neural disease such as Bells palsy/ stroke etc?
Do you have ,or have you previously had any other medical condition not already mentioned here.
Are you currently receiving any medical treatment?
Have you received any chemotherapy or radiotherapy in the last 12 months?
Have you had any surgery or physical injury in the last 12 months ?
Do you use, or have you ever used an Epipen?

When is your next menstrual period due?
Next menstrual period due
Have you had any issues of ill health, even the most minor, in the last 4 weeks? Give details
Details of ill health
Cancer - what type and how long ago?
Details of cancer
If you have had any other medical condition not already mentioned here, please give details.
other medical condition
Please provide details of any current medical treatment you are receiving
current medical treatment
Please provide details of any chemotherapy or radiotherapy treatment that you have had in the last 12 months?
chemotherapy or radiotherapy treatment
Please provide details of any surgery or physical injury you have had in the last 12 months ?
surgery or physical injury
Please provide detail of ALL medication you are currently taking, including the use of topical medications and drugs by injection?
current medication details
Please provide detail of ALL medications you have taken in the last 12months, including the use of topical medications and drugs by injection,stating when you finished the course of treatment.
medication details in last 12 months
Please add any further details of your health and medical history that has not otherwise been covered in this questionnaire
other health and medical history
CLIENT SELF ASSESSMENT
Which of the following do you feel best describes your skin type? Tick your answer

Very oily skin, large poresOily skinCombination skin, oily n T-Zone, dry to normal cheeks Normal well balanced skinDry SkinSensitive SkinBlemish prone skinAcne Skin ☐ Easily bruised skin
What are your main Hair concerns?
List your hair concerns
What results would you like to achieve from a course of treatment for any of your hair concerns?
Required results from treatment
Have you received any other Hair treatments within thelast 6 months? State how long ago
treatments within the last 6 months
Have you previously experienced any adverse scalp reaction to any hair treatment or product? Give details
adverse treatment/product reaction
Have you received any course of treatment which has proved ineffective or had disappointing results? Give details
ineffective treatment
Have you had any Hair Implantation surgery? Give details
hair implantation surgery details
Aesthetician Notes :
Aesthetician Notes :
Patient Name: Patient Name Date Signed Date
Patient Signature*

Clear
Witness Name: Patient Name Date Signed Date
Therapist Signature*

Clear
Should be Empty: