Online Skin Consultation

ONLINE SKIN CONSULTATION FORM

The more information you share, the better we can tailor a skincare plan to your unique needs.
PERSONAL DETAILS
Title
Full Name

First NameLast Name
DOB

DayMonthYear
Date
I confirm that I am over the age of 18 years old:
Address

Street Address

Street Address Line 2

CityCounty

Post Code
Contact Number
Email Address
GP Name & Address
Preferred method of contact:
MEDICAL INFORMATION

If the answer to any of the following questions is YES, please provide as much information as possible. Otherwise please type NO in the box.
Is there any chance you could be pregnant?
Are you breastfeeding?
Do you have any diagnosed medical conditions?
Please provide as much detail as possible
Are you currently under medical investigation or receiving treatment from a healthcare provider?
Please provide as much detail as possible
Are you currently taking any medications? This includes prescribed and over the counter medications
Please provide as much detail as possible
Do you have an autoimmune condition?
Please include whether the condition is well-controlled and if you have ever taken immunosuppressants
Do you suffer from any mental health conditions?
Please provide as much detail as possible
Do you have any allergies?
Please include type of reaction e.g. rash, anaphylaxis
Have you ever had a blood-borne virus? e.g. HIV, hepatitis
Do you have a history of any other serious illness?
Please provide as much detail as possible including dates and details of any treatment
Have you ever had facial surgery?
Please include type of surgery and dates and details of treatment
Have you ever had skin cancer?
Please include dates and details of any treatment
Are you prone to keloid scarring?
Are you prone to bleeding/bruising?
Are you prone to cold sores?
Please include how frequently you get them
Have you taken antibiotics within the last month?
Please include name of antibiotic and dates/duration of treatment
Are you currently undergoing any dental treatment?
Please include dates and details of treatment
FAMILY HISTORY
What is the ethnic background of your parents?
Do you have a family history of skin cancer?
Please provide as much detail as possible
LIFESTYLE INFORMATION
Occupation
Do you smoke or vape?
If YES, how many or how often per day?
Please specify if cigarettes, vape, cigars
Do you drink alcohol?
If YES, how many units per week?
If unsure on units, please specify types and amounts of alcoholic drinks e.g. bottles of wine, pints of beer
How would you describe your daily ACTIVITY/EXERCISE levels?

1

2

3

4

5

1 is Not Active, 5 is Very Active
How would you describe your current SLEEP quality?

1

2

3

4

5

1 is Low, 5 is High
How would you describe your current STRESS levels?

1

2

3

4

5

1 is Low, 5 is High
How often do you travel abroad or spend prolonged time outdoors in the sun? Please include any regular outdoor hobbies, work or holidays
Please provide as much detail as possible
Do you have any special events or important dates we should be aware of when planning your skincare/treatments?
DIETARY INFORMATION
Do you follow any type of special diet? e.g. vegan, vegetarian, pescatarian, dairy-free, gluten-free, kosher/halal, etc
Do you have any food intolerances? e.g. dairy, gluten, etc
Do you take any type of dietary supplements? e.g. vitamins, minerals, herbs, oils, prebiotics, probiotics, protein powder, meal replacements, etc
How would you describe your daily WATER consumption?

1

2

3

4

5

1 is Low, 5 is High
How would you describe your daily CAFFEINE consumption?

1

2

3

4

5

1 is Low, 5 is High
How would you describe your daily SUGAR consumption?

1

2

3

4

5

1 is Low, 5 is High
How would you describe your daily DAIRY consumption?

1

2

3

4

5

1 is Low, 5 is High
PREVIOUS TREATMENTS
Have you ever had botulinum toxin or dermal fillers?
If YES please provide details including product used, areas treated and dates of treatment (if known)
Have you ever had any other skin injectable treatment? e.g. Profhilo, Sculptra, polynucleotides, other skinboosters, etc
If YES please provide details including product used, areas treated and dates of treatment (if known)
Have you ever had a skin treatment? e.g. facial, chemical peel, Hydrafacial, microneedling, radiofrequency, laser, etc
If YES please provide details including product/device used, areas treated and dates of treatment (if known)
PERSONAL HABITS
How often do you change your bedding and pillowcase?
How often do you change your face towel/flannel?
How do you wash your face? e.g. in the shower, at the sink, using a cloth, with makeup wipes, etc
How often do you wear makeup?
Do you always remove makeup before bed?
Do you double cleanse?
What water temperature do you use when washing your face? e.g. cold, warm, hot
How would you describe your sleeping position? e.g. on front, back, side
Do you have pets that sleep in your bed at night?
Do you use fabric softener on bedding and towels?
How often do you clean your phone screen?
How soon after exercise/sweating do you cleanse your skin?
How would you describe your work environment? e.g. hot, humid, air-conditioned, dusty, outdoors, etc
Do you regularly swim in chlorinated pools?
Do you use hair products that come into contact with the face? e.g. hair dye
Do you regularly wear any of the following?
Do you use sun beds?
If YES, please provide details including how often
Do you use sunless tanning products? e.g. fake tan, spray tan
If YES, please provide details including how often
SKIN INFORMATION
What are your main skin concerns?
When did you first notice these skin concerns?
Are there any triggers that make your skin worse?

Other
How would you describe your skin type?

Other
Which of these apply to your skin?

Other
What is your current skincare routine?
Please provide as much information as possible including brand names, how long you have been using these products, how often they are used, if used in AM or PM, etc
Do you wear a dedicated SPF daily? (not including SPF in foundation or makeup)
How do you feel your current skincare is helping your skin?
Have you ever used skincare that caused an adverse reaction?
Please provide as much information as possible including brand names and what reaction occurred
Are you currently using, or have you recently used, any prescription or non-prescription retinoids?
e.g. retinyl palmitate, retinol, Tretinoin, Retin-A®, Tazorac®, etc.
Are you currently using, or have you recently used, any prescription topical medications?
e.g. creams, lotions, gels, ointments, sprays
Have you ever taken Roaccutane?
If YES please provide the dates and duration of your treatment
FINAL THOUGHTS
Has there been ANY recent changes to your medical history/diet/lifestyle/personal habits that you think could be affecting your skin?
Is there anything else you think is worth mentioning?
PHOTOGRAPHS

Upload photos to complete your skin assessment. They will not be shared without your consent.
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SIGNATURE
I confirm I have answered this to the best of my ability:
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ONLINE SKIN CONSULTATION FORM

PERSONAL DETAILS

MEDICAL INFORMATION

FAMILY HISTORY

LIFESTYLE INFORMATION

DIETARY INFORMATION

PREVIOUS TREATMENTS

PERSONAL HABITS

SKIN INFORMATION

FINAL THOUGHTS

PHOTOGRAPHS

SIGNATURE