PERSONAL DETAILS

Name *

Date

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Street Address *

Suburb *

Postcode *

Phone *

Email *

Occupation

Age (years)

Sex

• F
• M
• Other

CURRENT HOME CARE ROUTINE

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

How soon would you like to see results?

What is your home skincare regime? (Please tick the product(s) you use)

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:

CURRENT AND PREVIOUS TREATMENTS

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:

MEDICAL HISTORY

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

Females Only

Are you (Please tick):

• Pregnant
• Lactating
• Trying to conceive

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

LIFESTYLE

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:

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