Lauren Wood Naturopathy - Skin Care Assessment Form

Lauren Wood Naturopathy - Skin Care Assessment Form

*** If you know which specific products you're after and would like to bypass filling out the entire form, then please specify which products below and fill in the required areas with a red (*)
Are there any Dermaviduals products specifically that you're interested in purchasing? Otherwise, I will customise a skincare regime for you.
Date

MonthDayYear
Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Post CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
example@example.com
Are you happy to be contacted via phone to discuss your personalised skincare prescription?

YesNo, email only please
How did you hear about Lauren Wood Naturopathy?

Website / Online SearchFacebookInstagramReferralOther
If you were referred, please let us know who from. If Other please specify.
Are you currently using or have you used Dermaviduals in the past?
Your Skin
What are your skin care challenges?

Wrinkles / Fine LinesHyperpigmentation / Sun DamageAcne / Acne ScarringRedness / RosaceaAgingMelasmaSensitivityEczemaPsoriasisOther
Please feel free to go into more detail here, and list what your skin goals and objectives are?
Is your skin sensitive or reactive?
What skin type do you have?

OilyDryCombinationI don't know
Please feel free to list products / brands that you're currently using.
The below area is entirely optional. This will ask more details about your health so that I can determine what may be contributing to your skin presentation from a holistic perspective.

If you're only interested in skincare and not keen to delve further at this point then please disregard the below section and simply select submit.
Your Health
Have you experienced any of these health conditions in the past or present?

Hormone ImbalanceCancer / Systemic DiseaseIBSHigh Blood PressureGastrintestinal complaintsDiabetesArthritisConstipationAuto-Immune DisordersAsthmaFrequent Cold SoresDepression/AnxietyHeadaches / Migraines
If you checked yes to any of these please provide further information
Do you take any medications or dietary / health supplements?
Do you have any known allergies or intolerances?
Have you used or been prescribed any medications (topical or oral) for acne / acne control?

YesNo
If yes, please specify what and date last used
Do you smoke or vape?

YesNoSocial
Please rate your stress level

LowMediumHigh
Please let me know if you would like to learn about Naturopathic therapies to heal the skin from within and holistic health care advice
Would you like to learn more about the Microbiome and support for Gastrointestinal complaints?

Yes pleaseNo thank you, I'm just after skincare at this pointMaybe at a later date
Optional - For my analysis could you please upload a portrait photo in daylight without any makeup on. This is optional only, and required when you would like me to further assess your skin type and condition.

Cancelof
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this skin care professional from liability and assume full responsibility thereof.

Yes
Should be Empty:

Lauren Wood Naturopathy - Skin Care Assessment Form

Your Skin

Your Health