Cheshire Lasers Skin Consultation Form

Cheshire Lasers Skin Consultation Form
Full Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Mobile phone *
Occupation *
Are able to phone you should we need to discuss your appointment? *

Yes No
Are we able to email about your appointment? *

Yes No
Are you happy for us to text you about your appointment? *

Yes No
Would you like to receive our newsletter by Email (usually monthly)? *

Yes No
Where did you hear about the clinic?
Are you currently taking any medication or any supplements? *

Yes No
Do you have any medical problems or are you recovering from any medical treatment or operation within the last 12 months? *

Yes No
If yes to either of the above please specify the condition and the medication:
Do you have any allergies including metals, rubber silicone? If so what are you allergic to? *

Yes No
Is there any possibility of pregnancy or are you breast feeding? *

Yes No
Have you seen your GP about your skin? *

Yes No
Have you seen a dermatologist about your skin? *

Yes No
Have you attended a skin clinic for a consultation in the past? *

Yes No
If so which treatments have they tried? *

Benzoyl Peroxide Topical Retinoids Topical antibiotics Oral antibiotics Other please advise: Skin Care Peels Laser Microneedling
Did any of them help?

Yes No
Please advise
How familiar are you with the different treatments available?
If you are female are you on any contraception?

Yes No
If so what are you taking? Does this help or make it worse? Were you better on a different contraception?
Are you using any home care exfoliating skin care such as AHA’s or glycolic acid products on the treatment area? If so what are you using? *
What other products do you currently use on the treatment area? *
What are your goals/expectations for the treatment? *

Out of 5, where 5 is very much and 0 is not at all. How much does your problem bother you? *

	1	2	3	4	5

1 is Worst, 5 is Best

Can you explain why it bothers you?
Where 5 is very much and 0 is not at all. How much do you think it affects the following?

Your confidence *

	1	2	3	4	5

1 is Not at all, 5 is Very Much

Your social life *

	1	2	3	4	5

1 is Not at all, 5 is Very Much

Your employment or role at work *

	1	2	3	4	5

1 is Not at all, 5 is Very Much

How much does it impact you psychologically *

	1	2	3	4	5

1 is Not at all, 5 is Very Much

Does/ will your treatment help you psychologically? *

Yes No
Do you worry about your appearance *

Yes No
Do you suffer from anxiety symptoms or low mood or any other mental health problems? *

Yes No
Any other comments:
The information I have given is correct to the best of my knowledge, and I have not withheld any medical state or information. I will inform the IPL/Laser Technician before treatment if there has been any change (for example in medications). *

Clear
Should be Empty: