Online Skin Consultation

Client Information

Name

First Last

Phone

Date

DD slash MM slash YYYY

Medical Information

1. List any chronic medication you use and what it is used for

Medication

Use

2. List any vitamins and/ or supplements you take regularly

Vitamin / supplement

3. List any allergies you suffer from

Allergies

4. Are you currently applying Retin-A (Vitamin A cream prescribed by your doctor) to your skin?

Yes

5. Are you currently taking any medication for your skin, i.e. Roaccutane, Anti-biotics, the contraceptive pill, etc.

Yes

5.1 Please specify as well as the dosage.

Name of Medication

Dosage

6. Are you currently suffering from any skin diseases (eczema, psoriasis, acne, etc.)?

Yes

6.1 Please specify

Name of Skin Disease

Skin Health

1. List the type of treatments you have on your skin regularly

Type of treatment

2. Do you burn easily during sun exposure?

Yes

3. How much alcohol do you consume weekly?

List in amount of items (IE 1 / 2 / 10)

Please enter a number from 0 to 10.

4. How much caffeinated beverages do you consume daily?

List in amount of items (IE 1 / 2 / 10)

Please enter a number from 0 to 10.

5. How much plain water do you consume daily?

List in Litres of items (IE 1 / 2 / 5)

Please enter a number from 0 to 10.

6. Do you smoke?

Yes

7. Do you exercise?

Yes

8. Do you follow a restricted diet?

Yes

9. List all the skincare products you are currently using at home (Brand as well as product names)

Brand

Product Name

10. Are you pregnant or breast feeding?

Yes

11. Do you suffer from Epilepsy?

Yes

12. Do you have Diabetes?

Yes

13. Are you due for you menstrual cycle?

Yes

When is your next cycle due

MM slash DD slash YYYY

14. Rate your stress level

(1- no stress, 5 - very stressed)

15. Do you suffer with fever blisters (cold sores)

Yes

16. Do you have any immune disorders?

Yes

What immune disorders do you have

17. Please select your age group:

20 - 29

30 - 39

40 - 49

50 - 59

60 - 69

70 - 79

80+

Skin Information

Fitzpatrick Photo-type Classification

Based of the picture above select your Fitzpatrick classification(Required)

Skin Type

1. Select the most appropriate for your pore size

Large

Medium

Small

2. Select the most appropriate based on your oil production

Oily shine on my entire face during the day.

Oily shine only on my T-Zone.

I never have an oily shine during the day.

I have visible dry skin.

Skin Type

1. I experience stinging and burning on my skin from time to time

Yes

2. I have visible redness on my skin

Yes

3. I have had sensitivity to cosmetics in the past

Yes

Which Brands?

4. I have had an allergic reaction to cosmetics or skincare products

Yes

Which Brand?

5. I get blackheads on my skin

Yes

Which area on your skin?

6. I get whiteheads on my skin (small bumps under the skin)

Yes

Which area on your skin?

7. I get milia on my skin (white hard, visible bumps under skin)

Yes

Which area on your skin?

8. I get papules (inflamed pimples which doesn’t come to head, also known as a blind pimple)

Yes

Which area on your skin?

9. I get pustules (pimples with a white or yellow head).

Yes

Which area on your skin?

10. I have visible hyperpigmentation.

Yes

Please provide us with the following information

Which area on your skin?

How long have you had it?

What trigged it?

11. I experience skin tightness at times

Yes

12. I experience visible flaking at times

Yes

Your Concerns

Please list all your skin concerns.

Click the + do add additional concerns

Additional Notes

Please mention anything else you feel might be relevant to your skin consultation.

ONLINE

Client Information

Medical Information

Skin Health

Skin Information

Skin Type

Skin Type

Your Concerns

Additional Notes