DMK Consultation

Skin Consultation
CONFIDENTIAL
Name*

First NameLast Name
Customer #
Address

Street Number

Street

SuburbState

Post Code
Date of Birth

DayMonthYear
Work Phone
Mobile
Is it OK if we ?

send occasional SMS Marketing
send occasional Email Marketing
Email
example@example.com
Nationality/Family Background
Gender

MFNB
Medical History
Are you pregnant or breastfeeding?

YesNo
Do you have a regular menstrual cycle?

YesNo
Please list any medication you are currently taking and what you are taking it for.
Have you had any surgical procedures within the last 12 months?

YesNo
If yes, please stipulate.
Please list any current and previous medical conditions.
Please provide your doctor/physician’s name and contact number.
Please list all natural therapies/supplementation that you are or previously have taken.
Do you take any supplements for accelerated gym performance/protein powders frequently?
Do you take any anti-histamines or need the use of an epi-pen in the case of an allergic reaction?
Are you allergic to egg and/or do you have any other allergies?

YesNo
If yes, please stipulate.
Do you exercise? If so what type?
Do you drink alcohol? If yes, how many drinks would you consume in a week?
Do you smoke? If yes, how many a day?
Do you drink tea/coffee? If yes, how many a day? Sugar and milk?
How well do you sleep and how many hours would you get a night?
Please rate your stress levels.

1

2

3

4

5

6

7

8

9

10

1 is Not at all, 10 is Very chronic
Please tick here if you would like your therapist to discuss gut health with you.

YesNo
Your Skin Goals
What is it about your skin that you would like to improve?
How long has this been bothering you?
Rate how concerned you are about the condition of your skin.

1

2

3

4

5

6

7

8

9

10

1 is No concerned, 10 is It’s distressing
Do you have any areas on your body that may be of concern to you?
What does your current skin care routine consist of?
What brands are you using?
Have these achieved a result for you?

YesNo
Are you currently using AHA/highly active skin care?

YesNo
If yes, for how long and what brand?
Do you wear SPF daily?

YesNo
Please list previous professional skin treatments you have had to address your skin.
Have you had any skin peels in the last 12 months?

YesNo
If yes, please list the brand/type of peel and results.
Have you had any Intense Pulsed Light (IPL), Laser Resurfacing (fractionated or ablative) or Micro-needling in the last 12-18 months?

YesNo
If yes, please stipulate what was being targeted in your skin, the frequency and results.
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• Please sign the consent form prior to treatment.
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Skin Consultation

CONFIDENTIAL

Medical History

Your Skin Goals