THERMAVEIN SKIN QUESTIONNAIRE

CLIENT QUESTIONNAIRE
Name

First NameLast Name
DATE OF BIRTH

DayMonthYear
Date
Mobile Phone Number
Please enter a valid phone number.Format: (00000) 000000.
Email
example@example.com
Please confirm if any of the following statements apply*

I am pregnantI am breastfeedingI have a Pacemaker or implanted electronic deviceNone of the above apply
Where are the veins you are concerned about?

FaceLegsOther
Please indicate where your thread veins appear on your face (choose as many as you like)

NoseCentre of cheek(s)Entire cheek(s)ChinForeheadAround the eyeOther
Are there factors that seem to worsen the appearance or symptoms of your facial thread veins? (choose as many as you like)

Sun exposureTemperature changesStressOtherNone at all
How long have you had these symptoms?

Less than a month1-3 months4-6 months6-12 monthsOver 1 year
How have your veins impacted your emotional well-being or daily life in the past month? (choose as many as you like)

I feel self-conscious when my legs are visibleI avoid social or public activities because of my veinsMy veins make me feel older or less attractiveThe appearance of my veins affects my mood or self-esteemI feel restricted in my clothing choices due to my veinsMy veins have not affected me emotionally or socially
Have you experienced any of the following psychological symptoms in the last 2 weeks? (choose as many as you like)

My veins are negatively affecting my mental healthThe appearance of my veins is affecting my confidenceI can't wear clothing that shows my legsMy veins are affecting how I socialise
Have you previously been diagnosed with Deep Vein Thrombosis (DVT)?

YesNo
If you have previously received treatment for your thread veins, please select the type of treatment from the options below

LaserThermocoagulation treatment (Veinwave)Micro sclerotherapy treatmentOtherI did not receive any treatment
The appearance of thread veins can be significantly improved for most people by treating any underlying skin conditions. We'll now ask you a few questions about your skin to assess its potential role in the presence of your thread veins.
Do you have any of the following conditions? (Tick all that apply)?

RosaceaAcneBlood disordersKeloid scarringHyperpigmentationNone of the above
Have you experienced any of these symptoms

RednessSwellingRaised, solid pink spotsVisible thread veinsPus filled spotsThickened skinBurning feelingOther
Have you sought treatment for rosacea?

YesNo
What type of treatment did you receive?
This could include anything from oral antibiotics to creams. Please share all that apply to you.
On a scale of 1-10, how much has your rosacea improved after treatment?

1

2

3

4

5

6

7

8

9

10

1 is Not al all, 10 is Significantly
Are there any specific factors that worsen your rosacea?

AlcoholSmokingHormonalStressCaffeineOtherNo Contributors
Have you noticed any areas of discolouration or pigmentation irregularities on your skin?

YesNo
How would you describe the type of hyperpigmentation you're experiencing?

Dark spotsHormonal pigmentationSun spotsNot sure
Have you previously sought professional treatment for hyperpigmentation?

YesNo
What treatments or products did you use for hyperpigmentation?

Hydroquinone creamsArbutin creamVitamin C serums / creamsLaserNot sureOther
On a scale of 1-10, how satisfied are you with the results of previous treatments you have used for your hyperpigmentation?

1

2

3

4

5

6

7

8

9

10

1 is Not satisfied, 10 is Very satisfied
Which statement best reflects your acne?

A few acne spotsSome acne spots affecting less that half of the face with no cysts or nodulesMany acne spots affecting more that half of the face with some cysts and nodulesExtreme number of spots affecting most of the face with large cysts and nodulesPresence of scarring and/or pigmentation
Are you experiencing any specific types of acne?

BlackheadsWhiteheadsInflammed spotsFirm lumps
Have you previously sought professional treatment for your acne?

YesNo
Do you have any history of post-inflammatory hyperpigmentation (PIH) or skin that marks easily after procedures?

YesNo
Have you used any retinol, glycolic acid, or other exfoliating products in the last 5 days?

YesNo
Please list:
Are you currently taking any medication (esp. prescription topical creams, oral acne medication (eg. Roaccutane), antibiotics or blood thinners)?

YesNo
Please specify
Do you have a history of photosensitivity or reactions to light-based treatments (e.g. LED, laser)?

YesNo
Do you have any known allergies (especially to "Simple" wipes or "Aloe Vera gel")?

YesNo
Please Specify
Have you had recent sun exposure, used sunbeds, or plan to tan in the next 7 days?

YesNo
Do you have any upcoming events or holidays in the next 7 days?

YesNo
Please specify
If you are a suitable candidate for thermavein, how soon would you be looking to get treatment?

ASAPNext weekThis monthNext monthIn the next 3 monthsI'm still exploring options
DeclarationI confirm that the above information is accurate to the best of my knowledge. I understand that Thermavein is a minimally invasive treatment with some potential side effects, and that a full explanation will be provided during consultation.
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CLIENT QUESTIONNAIRE