AQ Hair complex+ Consultation Form

Client Name

First Name Last Name

Date of birth

Address

Street Address

Street Address Line 2

City County

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 Address

Street Address

Street Address Line 2

City County

Post Code

Doctor's Tel Number

Dr Mobile Phone number

What is your ethnic group?

Ethnic group

Do you wear contact lenses?

No Yes

CLIENT LIFESTYLE ASSESSMENT

What is you occupation?

Occupation

Do you work in a centrally heated or air conditioned environment?

No Yes

Are you city based?

No Yes

Do you work mainly outdoors?

No Yes

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 tan Burn easily and then tan Tan and rarely burn Never 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?

No Yes

Do you use a topical antioxidant?

No Yes

When was your last exposure to intense sunlight?

Intense sunlight

Are you planning an overseas holiday in the next 4 -6weeks?

No Yes

Have you ever had skin cancer?

No Yes

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

No Yes

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 pores Oily skin Combination skin, oily n T-Zone, dry to normal cheeks Normal well balanced skin Dry Skin Sensitive Skin Blemish prone skin Acne 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 :

Patient Name: Patient Name Date Signed Date

Patient Signature *

Clear

Witness Name: Patient Name Date Signed Date

Therapist Signature *

Clear