DMK Consultation

Skin Consultation
CONFIDENTIAL
Name

First NameLast Name
Customer #
Address

Street Number

Street

SuburbState

Post Code
Date of Birth

DayMonthYear
Work Phone
Format: 0000000000.
Mobile
Is it OK if we ?
Email
example@example.com
Nationality/Family Background
Gender
Medical History
Are you pregnant or breastfeeding?
Do you have a regular menstrual cycle?
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?
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?
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.
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?
Are you currently using AHA/highly active skin care?
If yes, for how long and what brand?
Do you wear SPF daily?
Please list previous professional skin treatments you have had to address your skin.
Have you had any skin peels in the last 12 months?
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?
If yes, please stipulate what was being targeted in your skin, the frequency and results.
Take Photo

click BROWSE and the camera can be selected
Cancelof
All information collected is strictly confidential | Information collected is for the benefit of the treatment.
• Please sign the consent form prior to treatment.
Signature
permissionsdummy
Should be Empty:

Skin Consultation

CONFIDENTIAL

Medical History

Your Skin Goals