Confidential Virtual Skin Consultation Form
Date
*
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Your Name
*
Address with town and postcode please
*
Home Phone
-
Area Code
Phone Number
Mobile
*
E-mail
*
Referred By
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you smoke and how many per day (If None say so)
*
Have you been treated for: (Please Check)
Can you list all allergies if any (If None say so)
*
List all medicines that you are currently taking (If None say so)
*
Are you Pregnant
*
Yes
No
Are you on Hormone Therapy
*
Yes
No
Are you prone to Cold Sores
*
Yes
No
Personal Information
Select your current level of stress
*
1
2
3
4
5
6
7
8
9
10
Low
High
1 is Low, 10 is High
Select your normal level of stress
*
1
2
3
4
5
6
7
8
9
10
Low
High
1 is Low, 10 is High
How many Litres of water do you drink per day
*
Do you take supplements / Vitamins
*
Yes
No
Do you Exercise
*
Yes
No
If you Exercise, explain how often
When were you last Sunburnt (If never say so)
*
Do you use Tanning Beds
*
Yes
No
When you go out in the sun do you (Check One only)
*
Always Burn
Usually Burn
Sometimes Burn
Rarely Burn
Very Rarely Burn
Never Burn
Have you ever been under the treatment plan of A
Dermatologist
Plastic Surgeon
Esthetician
If you have checked the previous question what Procedure or Treatment
Are you concerned about skin conditions on your body (Check all that apply)
Sun Spots
Skin Laxity
Dry / Rough
What skin products are you currently using (If None say so)
*
How do you feel About the overall quality of your skin
*
1
2
3
4
5
6
7
8
9
10
It could be better
Looks Great
1 is It could be better, 10 is Looks Great
Your skin type is (Check one only)
*
Normal
Dry / Dehydrated
Oily
Acne / Acne Prone
Rosacea
In order of importance please rank the following 5 questions for improvement in the next 30 days.
Reduction of fine lines
*
1
2
3
4
5
1 Star to 5 Stars (1 on the left, 5 on the right)
Acne scars diminished
*
1
2
3
4
5
1 Star to 5 Stars (1 on the left, 5 on the right)
Reduction of oil / acne
*
1
2
3
4
5
1 Star to 5 Stars (1 on the left, 5 on the right)
Reduction of brown spots / sun damage
*
1
2
3
4
5
1 Star to 5 Stars (1 on the left, 5 on the right)
Reduction of redness
*
1
2
3
4
5
1 Star to 5 Stars (1 on the left, 5 on the right)
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