Patient Skin Consultation Form Personal Details Name: Date: Phone: DOB: Sex: MaleFemale Street Address: Suburb: State: P/code: Email Address: Lifestyle What is your occupation? Do you work in a highly air conditioned environment? YesNo Do you work in front of a computer / tablet screen YesNo If so, how many hours per day? Do you follow a restricted diet? YesNo If yes, please specify: Do you drink caffeine? YesNo cups per week Do you drink alcohol? YesNo glasses per week How much water do you drink? litres per day Are your bowel movements regular? YesNo Are you prone to Constipation / IBS / Diarrhoea? NoConstipationIBSDiarrhoea Do you participate in vigorous sports or aerobic activity? YesNo If yes, please specify Do you go to tanning booths? YesNo Do you sunbathe? YesNo Do you use fake tanners? YesNo Please describe: Where did you grow up? Please describe your childhood sun exposure: Are you currently sun or wind burnt: How would you rate your current stress levels? Very LowLowModerateHighVery High Do you do anything to assist with stress relief e.g. mindfulness, yoga etc? YesNo Please Describe: Please List current or previous treatments: Have you received any of the following treatments in the last 14 days? Chemical PeelsFacial waxing /Electrolysis / Depilatory creamsDermal fillerPlasma PenMicrodermabrasionLight Based Treatments (Laser or IPL)BotoxEpidermal Levelling / DermaplaneDermal Needling / Collagen Induction TherapyRadio FrequencyOther Describe you reaction to treatment(s) received in the last 14 days: Have you had any Dermal Fillers or Botox in the last week? YesNo Have you ever had a peel before? YesNo Was it within the last 14 days? YesNo What kind? Describe your reaction: Have you had any facial surgery? YesNo If yes, please describe the nature of the surgery: Medical History Are you currently under physicians care for any medical conditions: YesNo Do you have any of the following health conditions? Hormonal imbalanceEczemaCold SoresHeart ConditionAsthmaDiabetesPsoriaisisKeloid ScarsHigh Blood PressureHayfeverEpilepsyThyroid ConditionThrombosisAutoimmune Disease Other (please describe): Please list any other medications or supplements you are currently taking including vitamins and herbs: Are you pregnant, lactating or trying to conceive? Are you allergic to any of the following: MilkApplesCitrusGrapesAloe VeraAspirinHair DyeNutsFragrance Please list any other allergies: What is your heritage? How do you heal from a cut? Brown pigmentPink then fades to white Are you using / have you previously used any of the following? • Prescription Retin YesNo How frequent is your use? Where do you apply it? • Roaccutane: YesNo How long have you been using / did use Roacutane? • Steroids or Steroid Creams: YesNo How frequent is your use? Where do you apply them? • Glycolic or other AHA home care products YesNo If so, which one(s)? How does your skin react to them? Current Home Care Routine What skin concerns would you like to improve? How soon would you like to see results? What is your current home skincare regime? Please list products and brands and frequency of use. AM PM Do any of your products contain AHA, BHA or Vitamin A? YesNo If so, which ones? Have you ever used any products that caused a bad reaction? YesNo Please describe:
