Name
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First Name
Last Name
Address
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Preferred Contact Number
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Email
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Occupation
Date of birth
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If you could change anything in your skin, what would it be?
Please tick as many areas of concern applicable
How do you heal from a cut?
Current Skincare Routine
List all the skincare products you currently use (cleansers, moisturizers, serums, etc.). Include brand names and specific product names if possible. Describe your morning and evening skincare routines in detail.
Have you had any cosmetic injectable services within 7 days of your scheduled appointment?
Have you had your eyebrows tattooed?
Skin Health History:
Provide details of any professional skin treatments you've undergone in the past
(chemical peels, laser, facials).
Any previous issues with skincare products causing irritation or adverse reactions.
Medical History:
Provide details of any chronic health conditions that may impact your skin. Have you had any recent surgeries or medical procedures. Note any changes in health status since your last visit to a healthcare professional.
Do you have or have you used Roaccutane, Vitamin A or a Vitamin A product prescribed by your Doctor
If yes, for how long, what strength and last time used, if known?
Please provide your doctor’s name & contact number
Medications/Supplements
Please list any medications or supplements that you’re currently taking.
Eg: warfarin, epi-pen, antihistamine, fish oil, protein powder,
Hormonal Factors:
For female clients: Provide details about your menstrual cycle, any hormonal contraceptives used, and any noticeable skin changes during different phases of your cycle.
Are you pregnant or breast feeding?
Have you been diagnosed with:
Skin Sensitivity:
Detail any known skin conditions
(e.g., eczema, psoriasis, rosacea).
Describe any recent skin sensitivities or reactions to specific ingredients or products.
Note any allergies that may affect your skincare choices.
Do you have any known allergies? For example: essential oils, egg, aspirin. Please provide details.
Do you experience hay fever or sinus issues?
Please tick if you’d like your therapist to discuss gut health with you.
Do you have any food intolerances? For example: coeliac, lactose intolerance, gluten intolerance. Please provide details.
Lifestyle Factors:
Describe your daily water intake and any efforts to stay hydrated.
Note any environmental factors that may affect your skin (e.g., exposure to pollution, extreme weather conditions).
Share information about your sleep patterns and the quality of your sleep.
Do you drink coffee, soft drink or other beverages? If yes, how many per day?
Do you exercise?
Do you drink alcohol? If yes, how many alcoholic beverages do you consume a week?
Do you smoke?
If yes, how many per day?
Please rate your stress levels
How well do you sleep and how many hours would you get a night?
Signature
Date
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