Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
County
Postal code
D.O.B (DD/MM/YYYY)
Email address
example@example.com
Phone number
What are your main skin concerns?
When did you first notice your concern?
Do you notice your skin concern gets worse at any time of the day/month/year?
Which of these statements is most applicable to you?
would like to look better for my age
would like to change something that has been bothering me
would like to look more attractive
After treatment I would like to feel-Please tick three
Fresher
Happier
Brighter
More awake
More youthful
More attractive
More illuminous
More confident
When I think about my appearance, I feel | look- Please tick any that apply to you
Dull
Tired
Sad
Angry
Old
Fresh
Happy
Bright
Unattractive
Which of these apply to your skin?
Lines (superficial)
Wrinkles
Decreased volume
Loss of elasticity (saggy skin)
Glycation (criss-cross wrinkles)
Dryness
Blackheads
Whiteheads
Cysts (boils)
Acne Scarring
Sallow (yellow/dull) complexion
Oiliness
Open pores
Hyperpigmentation (brown spots)
Hypopigmentation (white spots)
Uneven skintone
Freckles
Broken capillaries
Inflammation
Redness
Sensitivity
Do you have any drug allergies?
Yes
No
If the answer is Yes to the above question, please provide details
Are you pregnant or breastfeeding?
Yes
No
Are you using any prescription or non-prescription retinoids (eg. retinol, Retin-A®, Tazorac®)
Yes
No
Are you using any prescription topical medications at this time?
Yes
No
Are you taking any medication prescribed by your GP?
Yes
No
Please provide a list of prescription medication
Have you ever used skincare products that caused an adverse reaction?
Yes
No
If you answered YES to any of these, please explain further
Do you have any past medical history
Have you had an aesthetic consultation or treatment before?
Yes
No
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?
What is your current skincare routine, both morning and evening?
Please document which products you are using and if they are helping your skin.
Are there any specific products you would like to try?
Which of these are of interest you?
Skincare
Chemical Peels
Facials
Skin Injectables
Micro-needling
Muscle relaxant injections
Skin lesion removal
To be able to gain a full understanding of your skin needs, please continue and complete your questionnaire by providing clear, photographs in a good light.
Take Photo
Take Photo
Take Photo
Signature
Date
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Month
-
Day
Year
Date
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