Skin Barrier Restoration Intake ✨🩺

Skin Barrier Restoration Intake ✨🩺

Please provide detailed information about your skin condition, health history, and lifestyle to help us tailor your treatment plan.
Patient Identity and Contact Information
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex / Gender
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method
Symptom Details
Affected body locations

Other
How long have symptoms been present? (days)
Dryness severity

1

2

3

4

5

6

7

8

9

10

1 is Mild, 10 is Severe
Flaking severity

1

2

3

4

5

6

7

8

9

10

1 is Mild, 10 is Severe
Itching severity

1

2

3

4

5

6

7

8

9

10

1 is Mild, 10 is Severe
Cracking severity

1

2

3

4

5

6

7

8

9

10

1 is Mild, 10 is Severe
Bleeding severity

1

2

3

4

5

6

7

8

9

10

1 is Mild, 10 is Severe
Treatments and Topical Exposures
Conventional treatments already tried

Other
Topical products currently used
Topical ingredients used
Contact irritants and exposures

Other
Occupational Exposures
Do you work in a healthcare setting or similar role?

Yes, other healthcare role
Which workplace skin exposures apply to you?

Other
How often do you wash your hands at work?
What is your typical work schedule?
Please describe any other notable workplace exposures that may affect your skin.
Hydration and Shower Habits
Average daily water intake
How often do you shower or bathe?
Typical shower duration
Usual shower water temperature
Which of the following apply to your cleansing and moisturizing routine?

Other
Diet and Digestive Health
How would you describe your overall diet pattern?

Other
How often do you eat omega-3-rich foods (such as salmon, sardines, chia, flax, or walnuts)?
How often do you consume seed oils (such as soybean, corn, sunflower, safflower, canola, or grapeseed oils)?
Which digestive symptoms do you experience?
Do you have a history of food sensitivities or food reactions? Please describe any known trigger foods.
Are there any dietary patterns, foods, or ingredients that seem to worsen your skin or digestive symptoms?
Hormonal, Metabolic, Stress, and Sleep History
Thyroid-related symptoms

Other
History of insulin resistance or blood sugar concerns

Other
Perimenopause or menopause status

Other
Hormonal or menstrual-related skin changes

Other
Current stress level

1

2

3

4

5

6

7

8

9

10

1 is Very low, 10 is Very high
Sleep quality and average duration
Medications, Supplements, Allergies, and Prior Labs
Current medications
Current supplements
Medication, supplement, or topical product reactions
Known allergies or sensitivities
Prior lab results
Other relevant medical records or lab details
Goals, Expectations, and Triage
What are your main goals for care?

Other
How quickly are you hoping to see improvement?
What outcome would feel like a successful treatment plan for you?
Do you currently have any signs of skin infection?
Are you having severe or worsening pain?
Has the rash been spreading quickly?
Do you have fever, chills, open wounds, or any urgent symptoms that need prompt dermatology evaluation?
Consent and Program Interest
Consent Acknowledgement
Which services are you interested in?
Should be Empty:

Skin Barrier Restoration Intake ✨🩺

Patient Identity and Contact Information

Symptom Details

Treatments and Topical Exposures

Occupational Exposures

Hydration and Shower Habits

Diet and Digestive Health

Hormonal, Metabolic, Stress, and Sleep History

Medications, Supplements, Allergies, and Prior Labs

Goals, Expectations, and Triage

Consent and Program Interest