Health Questionnaire

The first step is to complete the skin health assessment so that we know in advance what your skin concerns are and what you would like to achieve for your skin.

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Email *

Confirm Email

Phone *

Gender *

Male
Female

Date of Birth *

What is the best way to contact you? *

Phone
Email
SMS

How did you hear about us? *

Referral
Social Media
Google
Advertisement
Other

What is the reason for your consultation? *

What special areas of concern do you have? Tick any that apply.

acne scarring
fine lines and wrinkles
hair removal
pigmentation
sun damage
stretch marks
age spots
scars
acne
other (give details below)

Do you? Tick which apply, if any.

Sunbathe
Use Tanning Beds

How often?

Have you ever had (tick all that apply)

Microdermabrasion
Laser Hair Removal
Restylane
Botox
Body Treatments
Cosmetic Surgery
Cosmetic Fillers
Collagen Injections
Chemical or Natural Peels

Comments

Do you Bruise Easily? *

Do you get cold sores/blisters? *

(Herpes Zoster/Shingles)

What medications/hormone relacements/vitamins do you take?

Have you ever used (tick all that apply)

Accutane
Retin-A
Renova
Topical Antibiotic
Hydroquinone

Personal or Family History of Cancer? *

If so, please give details

Are you under the care of a Physician? *

If so, please give details

Have you ever had Botox or any other filler? *

If Yes, how long ago?

Have you ever had a reaction to

Metals
Medication
Food
Fragrance
Airborne Particles
Cosmetics
Other Alergans (milk, apples, citrus, grapes, aloe vera, aspirin)

Do you wear contact lenses? *

FOR MEN

Do you experience breakouts? *

Yes
No
Not applicable (women to select)

Do you have ingrown hair? *

Yes
No
Not applicable (women to select)

FOR WOMEN

Are you on Birth Control? *

Yes
No
Not applicable

Do you take hormone replacement? *

Yes
No
Not applicable

Are you pregnant? *

Yes
No
Not sure
Not applicable

How would you describe your overall health? *

Poor
Fair
Good
Excellent

Have you had any of the following:

Acne *

Allergies *

Arthritis or Bursitis *

Irregular Blood Pressure *

Breast Implants *

Have you had any of the following

Cancer *

Cataracts *

High Cholesterol *

Claustrophobia *

Diabetes *

Diarrhoea/Constipation *

Have you had any of the following

Eczema *

Epilepsy *

Hay Fever *

Headaches *

Heart Problems *

Hepatitis *

Have you had any of the following

Hirsutism *

HIV *

Hormone Imbalance *

Infections *

Lupus *

Have you had any of the following

Metal Implants *

Pacemaker *

Phlebitis *

Psoriasis or Vitiligo *

Serious Injury *

Thyroid *

Varicose Veins *

LIFESTYLE AND DIET

Do you normally sleep well? *

Do you smoke? *

Do you regularly exercise? *

Do you have food intolerances? *

If yes, please explain

Do you follow any special diet? *

If yes, please explain

What is your stress level? *

Low
Medium
High

Daily water intake (no. glasses per day)

Selected Value: 0

Daily caffeine-type beverage intake (no. cups of coffee/tea/soft drinks)

Selected Value: 0

Which of these do you consume on a daily basis?

Protein
Complex carbohydrates
Vegetables & salad
Fruit

How would you rate your skin? Select One *

Always burns, never tans
Burns easily, tans slightly
Burns moderately, tans gradually
Seldom burns, always tans well
Rarely burns, deep tan
Never burns, deeply pigmented

Ethnic Background *

Irish/English
Asian
Hispanic
African American
Polish/Hungarian
German/Dutch
Native American
Russian
Italian/Mediterranean
Other (describe below)

Other Ethnic Background

How would you describe your skin? (tick all that apply)

Normal
Oily
Dry
T-zone/Combination
Freckled
Sun-Damaged
Uneven
Blotchy
Mature
Wrinkled
Saggy
Firm
Large Pores
Small Pores
Acne
Milia
Comedones
Occasional Breakouts
Scarred
Cystic
Melasma
Florid
Rosacea
Asphyxiated
Swallow
Perfumed-stained
Hypopigmented
Post-Inflammatory
Hyperpigmented

Eye Colour *

Blue
Green
Hazel
Grey
Light Brown
Dark Brown

Natural Hair Colour *

Blonde
Red
Light Brown
Medium Brown
Dark Brown
Black
White
Grey/Silver

Skin Tone *

Pale/White
Light
Light Olive
Medium Olive
Dark Olive
Brown
Black
Reddish/Freckles

Commitment

How committed are you to achieving results? *

Not Sure
Mildly Committed
Very Committed

We will discuss certain recommendations to assure success in your treatment programme such as daily water intake and/or home care regime. During the course of your treatment, it may be necessary to recommend adjustments to your programme. Would that be OK with you? *

Your Practitioner will recommend the appropriate schedule for future treatments in order to achieve your goals.

Informed Release

I fully understand all the questions above and have answered them correctly and honestly. I understand that the services offered are not a substitute for medical care. I understand that the practitioner will completely inform me of what to expect in the course of treatment and will recommend adjustments to my regimen if deemed necessary. I am aware that individual results are dependent upon my age, health, condition and lifestyle. I agree to actively participate in following appointment schedules and home care procedures to the best of my ability, so that I may obtain maximum effectiveness. In the event that I may have additional questions or concerns regarding my treatment or suggested home product routine, I will inform my practitioner immediately. I release the Therapist and the staff harmless from any liability that may result from this treatment. *

I agree with the above statement

Please upload 3 clear images of your skin (png, jpg, gif or pdf). *

Click or drag files to this area to upload. You can upload up to 3 files.

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Health Questionnaire

Health Questionnaire

FOR MEN

FOR WOMEN

Have you had any of the following:

Have you had any of the following

Have you had any of the following

Have you had any of the following

Have you had any of the following

LIFESTYLE AND DIET

How would you describe your skin? (tick all that apply)

Commitment

Informed Release

Opening Hours

Company Policies

Health Questionnaire

FOR MEN

FOR WOMEN

Have you had any of the following:

Have you had any of the following

Have you had any of the following

Have you had any of the following

Have you had any of the following

LIFESTYLE AND DIET

How would you describe your skin? (tick all that apply)

Commitment

Informed Release

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Opening Hours

Company Policies