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?

    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?

    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?

    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?

    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:

    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: