Name * First Name Last Name Email * Age Do you consider your skin Sensitive Resilient Unsure Describe your skin check all the apply Normal Dry T-zone/ combination Thick Thin Saggy Firm Oily Acne Comedones/Blackheads Milia Cysts Breakouts Acne-scared Large pores Small pores Rosacea Eczema Freckled Sun-damaged Melasma Hyperpigmentation Hypopigmentation Uneven / blotchy Mature Wrinkled Patchy dryness Sallow Psoriasis Dehydrated/lacking moisture Asphyxiated Telangiectasia/broken surface capillaries Dermatitis What are the changes you’d most like to see in your skin Your health INFORMATION IS TO ENSURE WE CARRY OUT THE APPROPRIATE TREATMENTS FOR YOU, TAKING INTO CONSIDERATION ANY MEDICAL CONDITIONS WHICH MIGHT HAVE TREATMENT CONTRAINDICATIONS pregnancy heart condition dermatitis menopause diabetes headaches/migraines high blood pressure asthma epilepsy skin cancer thyroid - hyper or hypo water retention varicose veins how frequently do you exercise: everyday 3 x week 1 x week never Other how would you describe your diet: balanced on the run very unbalanced Do you smoke: Yes No Do you drink alcohol: daily occasionally never do you drink coffee: 1 x day 2 x day More than 2 x day which areas concern you the most in terms of aging? face eye area décolleté hands have you ever experienced any of the following? Chemical peels Laser resurfacing Retinoid prescriptions Regular collagen, Botox or other dermal filler injection Have you ever undergone Accutane therapy Are you allergic/sensitive Milk Apples Citrus Grapes Aloe Vera Aspirin Perfumes Latex Hydroquinone Mushrooms If any other allergies, what? Have you ever used any other products that caused a bad reaction Do you use any of the following? cleanser soap toner exfoliator mask eye cream day moisturizer night moisturizer sunscreen serum / concentrate / booster peels Other YOUR BODY are you concerned with any of the following body conditions? weight loss of skin tone muscle tone elasticity varicose veins/broken capillaries heavy legs dry skin cellulite stretchmarks bust area - lack of tone dry hands dry feet Do you use any of the following?: body scrub body moisturizer cellulite products bust products hand cream foot cream what is your primary concern? Privacy statement The skincare history and health information you have provided are used to help the therapist recommend skin care treatments and homecare products that are suitable for your skin and condition. It is accessible to authorized staff for that purpose only and may be accessed by you at any time. guest’s signature: Date MM DD YYYY Thank you!
