SECHI SKIN CLINIC CONSULTATION FORM

Name
Post code
Phone number
Format: (000) 000-0000.
Email address
example@example.com
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
I am using any prescription topical medications at this time
YesNo
YesNo
If you answered YES to any of these, Please explain further
What is the ethnic background of your parents?
Do you have any medical issues?
What is the main reason for your enquiry today?
would like to look better for my agewould like to change something that has been botheringwould like to look more attractive
YesNo
Most daysWeeklyMonthly
DullTiredSadAngryOldFreshHappyBrightUnattractive
On a scale of 1 10, 1 being desperately unhappy and 10 being extremely happy, how satisfied are you with your appearance?
On a scale of 1 - 10, 1 being desperately unhappy and 10 being extremely happy, how satisfied are you with your skin?
On a scale of 1 10, 1 being desperately unhappy and 10 being extremely happy, how satisfied are you with your skin?
FresherHappierBrighterMore awakeMore youthfulSlimmerMore attractiveMore illuminousMore confident
What are your main skin concerns?
When did you first notice your concern?
Lines (superficial)WrinklesDecreased volumeLoss of elasticity (saggy skin)Glycation (criss-cross wrinkles)DrynessBlackheadsWhiteheadsCysts (boils)Acne ScarringSallow (yellow/dull) complexionOilinessOpen poresHyperpigmentation (brown spots)Hypopigmentation (white spots)Uneven skintoneFrecklesBroken capillariesInflammationRednessSensitivity
Do you notice your skin concern gets worse at any time of the day/month/year?
What is your current skincare routine?
How is your current skincare helping your skin?
Are there any specific products you would like to try?
SkincareChemical PeelsIPLMicrodermabrasionFacialsDermaplaningPigment reduction - cryotherapySkin TighteningSkin InjectablesMicro-needlingMesotherapyLaserMuscle relaxant injectionsFacial FillersFacial ThreadsBrow correctionThread vein removalFat reduction
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