Patient Consultation Form - ByStella

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PATIENT CONSULTATION FORM

Name *

Street Address *

Suburb *

Postcode *

Email *

Occupation

Age (years)

Sex

F
M
Other

What skin concern(s) would you like to improve?

How soon would you like to see results?

Morning

Cleansers / Toners
Serums
Eye Products
Moisturiser / Sunscreen
Masks

Evening

Cleansers / Toners
Serums
Eye Products
Moisturiser / Sunscreen
Masks

Other (please describe):

Do any of your current home care products contain AHA, BHA or Vitamin A? If so, which ones?

Have you ever used any products that caused a bad reaction? Please describe the reaction:

Have you received any of the following treatment(s) in the last 14 days?

Chemical Peels
Dermal Filler
Plasma Lifting
Microdermabrasion
Botox
Epidermal Levelling
Radio Frequency
Light based treatment (Laser or IPL)
Dermal Needling / Collagen Induction Therapy
Facial waxing / electrolysis / depilatory creams

Other:

Describe your reaction to the treatment(s) you have received in the last 14 days:

Have you had facial surgery in the last 12 months?

Yes
No

If yes, Please describe the nature of the surgery:

Are you currently under a physician’s care for any medical conditions?

Yes
No

Do you have any of the following health conditions? (Please tick all that apply)

Hormonal imbalance
Eczema
Cold Sores
Heart Condition
Asthma
Diabetes
Psoriasis
Keloid Scars
High Blood Pressure
Hay fever
Epilepsy
Thyroid Condition
Asthma
Thrombosis
Autoimmune Disease

Other (please describe):

Are you using/ have you previously used any of the following?

Roaccutane
Prescription Retin A
Steroids or steroid creams

Roaccutane: How long have you been using / did use Roaccutane?

Prescription Retin A: How frequent is your use?

Steroids or steroid creams: Where do you apply it?

Please list any other medications / supplements you are currently taking (including vitamins and herbs):

Are you allergic to: (Please tick all that apply)

Milk
Apples
Citrus
Grapes
Aloe Vera
Aspirin
Hair Dye
Nuts
Fragrance

Please list any other allergies:

How do you heal from a cut? (Please tick):

Brown pigment
Pink then fades to white

Are you (Please tick):

Pregnant
Lactating
Trying to conceive

Are you taking any contraceptives or hormone supplements? If yes, please specify:

Do you participate in vigorous sports or aerobic activity?

Yes
No

If yes, what type?

Do you follow a restricted diet?

Yes
No

Do you drink caffeine?

Yes
No

Cups Per Week:

Do you drink alcohol?

Yes
No

Glasses Per Week:

Have you had any recent sun exposure (including tanning booths)?

Yes
No

Do you smoke?

Yes
No

How would you rate your current stress levels:

Very Low
Low
Moderate
High
Very High

Consulting Skin Specialist:

Comment

Signature Services

Skin Rejuvenation
Cosmetic Tattooing
Bridal & Events
Education

Get in Touch

110a Nicholson Parade,
Cronulla NSW 2230
Phone to Book: 1300 001 218
Click to Request Appointment

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