Have you used Alpha Hydroxy Acids (AHA) or Glycolic products (BHA) in the last 48-72 hours?*
YesNo
Are you using or have used in the last 6-12 months Retin-A, Renova, Accutane(an oral form of Retin-A)?*
Are you using any skin thinning products or drug, e.g hydrocortisone cream?*
Are you pregnant/planning or nursing?*
Are you exposed to the sun or sunbeds?*
Do you suffer from Epilepsy or Diabetes?*
Are you currently taking and medications? If yes please list:*
Are there other medical conditions or issues that your therapist should be aware of? If yes please list:*
Have you ever been treated for Cancer? If yes, when and what types of therapies were used?*
Do you wear contact lenses?*
Do you have any Allergies e.g Aspirin, allergies to ingredients in products, If yes please list:*
Do you have any skin conditions such as psoriasis or eczema?*
Do you have any recent scars(under 6 months old) or suffer from keloid scarring?*
What is your stress levels between 1-5?*
Do you exercise and how often?*
How much sleep do you get per night?*
How much water do you drink a day?*
Do you have a healthy diet?*
Are you taking the contraceptive pill?*
Do you smoke? If yes how many:*
Do you consume a lot of sugar?*
Do you consume a lot of dairy?*
Do you take any vitamins or supplements? Please list if yes:*
What is your main concern with your skin?*
What would you like to see achieved with your skin?*
Have you ever had a Chemical Peel, Laser, or Microdermabrasion? If yes which treatment and when was it last done?*
What skincare products are you currently using?*
CleanserTonerSerumSpfNight MoisturiserDay MoisturiserEye CreamExfoliaterMask
What Brand of skin products are you currently using? Please list:*
Do you use a SPF every day?*
Do you include retinol products in your skin routine?*
How sensitive is your skin? Please tick:*
MildMorderateVery sensitiveNot sensitive
What Areas of concern do you have regarding your skin: Please tick any that apply*
Breakout proneExcessive oil/shineRosaceaBroken CapillariesRedness/ruddinessDehydratedSun spotUneven skin toneSun Damage/pigmentationWrinkles/Fine LinesDry e.g tight/flackyAcneDullSensitiveFlakyCombination e.g dry cheeks/oily T zone
Do you get Any of the following: Please tick:*
BlackheadsMiliaPustules/ whiteheadsCystic AcneOccasional spotsHormonal BreakoutsNever Breakout
Do you do a AM and PM skin routine? Please tick:*
AMPM
Do you wear Make up every day?*
Do you wear a Mineral based Make up?*
