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SERVICES
PRODUCTS
HE-SHI
WAXPERTS
SKINICIAN
BEAUTY TREATS
SHOP ALL
FAQ
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0
Cart
Skin Consultation form
Mrs
Miss
Ms
Mr
Name
Address
Post code
Contact Phone Number
e-mail address
Age
20-30
31-40
41-50
51-60
61+
Have you been under medical care in the last 6 months?
Yes
No
If yes please give details
Have you undergone surgery within the last 6 months?
Yes
No
Please list any medications, diuretics, supplements, vitamins you take regulary
Please list any ongoing health concerns
Please list any allergies
Rate your Stress Level with 1 being the lowest and 5 the highest
1
2
3
4
5
Is your sleep disturbed?
Yes
No
Do you exercise regularly?
Yes
No
Do you use sunbeds or sun bathe?
Yes
No
Do you smoke?
Yes
No
Do you follow a restricted diet?
Yes
No
What SPF do you use?
How much water do you drink daily?
How many caffeinated beverages do you drink daily?
How many alcoholic beverages do you consume weekly?
Taking the contraceptive pill?
Yes
No
Pregnant or trying to become pregnant?
Yes
No
Experiencing menopausal symptoms?
Yes
No
Breastfeeding?
Yes
No
Have you ever had a skin reaction?
Yes
No
Do you ever experience sinus problems?
Yes
No
Have you ever experienced any stinging?
Yes
No
Do you experience any redness?
Yes
No
Do you experience flushing and blushing?
Yes
No
Do you experience flakiness and tightness?
Yes
No
Do you experience an oily shine?
Yes
No
Do you experience breakouts?
Yes
No
What are your main skin concerns?
What is your current skin care routine?
What would you like to achieve from your treatment today?
Do any of your products contain resurfacing ingredients such as Vitamin A / Retinol / Retain A / Hydroxy Acids / Fruit enzymes?
Yes
No
Within the last 6 months have you used any medically prescribed acne products e.g.: Roaccutane /Retinol / Retain A/ Retinova / Tarozac / Other?
Yes
No
Have you ever experienced chemical peels?
Yes
No
Have you had any resurfacing treatments in the last 3 months / 6 months?
Yes
No
In the last 3 months have you had any advanced treatments such as, Micro-needling / Fillers / Botox?
Yes
No
give permission for my personal details and treatment history to be kept on record in compliance with General Data Protection Regulations:
Send
Full Name:
Mobile
Date of Birth
Email
Address
Occupation
Sex
Are you currently seeing your doctor for any medical conditions?
No
Yes
Are you taking any medication?
No
Yes
If yes please List
Do you have any allergies (including salicylic/ aspirin, nut or latex)?
No
Yes
Do you have any of the following?
Lupus
Diabetes
Hormonal Imbalance
Pacemaker
Broken Veins
High / Low Blood Pressure
What is your current level of stress? (Low 1 – High 10)
Have you been diagnosed with HIV positive, AIDS or Hepatitis C?
No
Yes
Have you or any members of your family had cancer or skin cancer?
No
Yes
Have you ever had chemotherapy / radiotherapy?
No
Yes
Have you had a skin allergy/ reaction after a treatment?
No
Yes
Have you ever seen a dermatologist?
No
Yes
Do you use any topical medications?
No
Yes
Do you have eczema / psoriasis?
No
Yes
Have you undergone any cosmetic procedures?
No
Yes
Do you have any other allergies/ intolerances to cosmetic ingredients,
No
Yes
If yes please list:
Are you prone to cold-sores / lip herpes?
No
Yes
Could you be pregnant, planning a pregnancy or breast feeding?
No
Yes
Do you sunbathe or use sunbeds?
No
Yes
Are you planning a sun holiday in the next 6 weeks?
No
Yes
Do you suffer from claustrophobia?
No
Yes
Do you suffer from asthma?
No
Yes
Do you wear contact lenses?
No
Yes
Do you undertake any exercise?
No
Yes
Do you smoke or live with anyone who smokes?
No
Yes
What is your daily water intake?
What is your current skincare regime? Please list all products your currently use on your skin.
List the main areas of concern on your face:
Highlighting your top skin priority that you wish to see an improvement on.
What outcome do you want from your consultation today?
Are you interested in:
Facials
Peels
Micro-needling
Send
