All new customers please fill out these questions and email us and wait for us to get back to you. Easiest way is to click on this link and download the form and email it retreatskinandbeauty@gmail.com
https://store-8ot8tf5it.mybigcommerce.com/content/new%20client%20form.pdf
ONLINE SKIN EVALUATION
Name: _______________________________________________________ Date: _____________________________ Skin Specialist: ________________________________________________
IMAGES PROVIDED (Please tick):
◻ Left Side Image ◻ Right Side Image ◻ Front Image
MAIN CONCERN: ________________________________________________________________________________ Impact Scale: ______ / 10
Possible Cause: __________________________________________________________________________________ Current and previous treatments to address concerns: __________________________________________________ _______________________________________________________________________________________________
ADDITIONAL CONCERNS: ___________________________________________________________________________ Impact Scale: ______ / 10
Possible cause: __________________________________________________________________________________ Current and previous treatments to address concerns: ___________________________________________________ _______________________________________________________________________________________________
Lifestyle: _______________________________________________________________________________________ _______________________________________________________________________________________________ Medical History: _________________________________________________________________________________ _______________________________________________________________________________________________
Diagnosed Skin Disorders: __________________________________________________________________________
TREATMENT PLAN:
Treatment Preparation: ____________________________________________________________________________ Stage 1: Strengthen and Prime: _____________________________________________________________________ Stage 2: Intensive: ________________________________________________________________________________ Stage 3: Maintenance: ____________________________________________________________________________
ONLINE SKIN EVALUATION 12 POINT SKIN ASSESSMENT
Fitzpatrick Skin Phototype: I II III IV V VI Glogau Scale of Photo damage: 1 2 3 4
Sensitivity
◻ Reactive _____________________________________________________________________________________________________ ◻ Impaired barrier _______________________________________________________________________________________________ ◻ Unresponsive _________________________________________________________________________________________________
Vascularity
◻ Normal ______________________________________________________________________________________________________ ◻ Insufficient___________________________________________________________________________________________________ ◻ Dysfunctional _________________________________________________________________________________________________ ◻ Post Acne Erythema ____________________________________________________________________________________________
Dehydration
◻ Mild ________________________________________________________________________________________________________ ◻ Moderate ____________________________________________________________________________________________________ ◻ Severe ______________________________________________________________________________________________________
Keratinisation
◻ Normal ______________________________________________________________________________________________________ ◻ Hyperkeratinised ______________________________________________________________________________________________ ◻ Thin ________________________________________________________________________________________________________
Skin Thickness – skin fold test on forehead, upper lip and lateral orbital rim
◻ Thin: 6 – 10 lines _____________________________________________________________________________________________ ◻ Medium: 3 – 5 lines ___________________________________________________________________________________________ ◻ Thick: 2 -3 lines ______________________________________________________________________________________________
Pore size
◻ Very fine ____________________________________________________________________________________________________ ◻ Enlarged ____________________________________________________________________________________________________ ◻ Sebaceous hyperplasia _________________________________________________________________________________________
Lipid production
◻ Lipid dry _____________________________________________________________________________________________________ ◻ Normal ______________________________________________________________________________________________________ ◻ Combination _________________________________________________________________________________________________ ◻ Oily ________________________________________________________________________________________________________
Pigmentation
◻ Ephilides _____________________________________________________________________________________________________ ◻ Melasma ____________________________________________________________________________________________________ ◻ Solar Lentigo _________________________________________________________________________________________________ ◻ Post Inflammatory Hyperpigmentation _____________________________________________________________________________ ◻ Acquired Bilateral Nevus of Ota Like Macules (ABNOM_________________________________________________________________ ◻ Periorbital Melanosis ___________________________________________________________________________________________ ◻ General Dyschromia____________________________________________________________________________________________ ◻ Hypopigmentation _____________________________________________________________________________________________
Rosacea Stage (if applicable) _____________________________________________________________________________________________ Acne Grade (if applicable) _______________________________________________________________________________________________
Annexure E – AST skin consultation form
PATIENT CONSULTATION FORM
Name: ______________________________________________________ Date: _____________________ Street Address: __________________________________ Suburb: ________________________________ Postcode: ___________ Phone: _________________ Email Address: ____________________________ Occupation: _________________________________ Age (years): _________________ Sex: F / M / Other
What skin concern(s) would you like to improve?
____________________________________________________________________________________
How soon would you like to see results?
____________________________________________________________________________________
CURRENT HOME CARE ROUTINE
Where are you currently purchasing your products from?
❑ Supermarket ❑ Department Store ❑ Pharmacy ❑ Skin Clinic ❑ Online/Other What is your home skincare regime? (Please tick the product(s) you use)
|
MORNING |
EVENING |
|
❑ Cleansers / Toners |
❑ Cleansers / Toners |
|
❑ Exfoliants / Scrubs |
❑ Exfoliants / Scrubs |
|
❑ Serums |
❑ Serums |
|
❑ Eye Products |
❑ Eye Products |
|
❑ Moisturiser |
❑ Moisturiser |
|
❑ Sunscreen |
❑ Masks / Other: |
|
❑ Make Up / Other: |
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 ❑ Microdermabrasion ❑ Laser or IPL ❑ Facial waxing / electrolysis ❑ Skin Needling ❑ Dermal Filler ❑ Plasma Lifting ❑ Other:___________________
❑ Epidermal Levelling ❑ Anti-Wrinkle Injections ❑ Radio Frequency
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? Y / N
If yes, please describe the nature of the surgery: ______________________________________________
PATIENT CONSULTATION FORM
MEDICAL HISTORY
Are you currently under a physician’s care for any medical conditions? Y / N Do you have any of the following health conditions? (Please tick all that apply)
❑ Hormonal imbalance ❑ Diabetes
❑ Epilepsy
❑ Eczema
❑ Psoriasis
❑ Thyroid Condition ❑ Cold Sores
❑ Keloid Scars
❑ Asthma
❑ Heart Condition
❑ High Blood Pressure ❑ Thrombosis
❑ Asthma
❑ Hay fever
❑ Autoimmune Disease
❑ Other (please describe):__________________
Are you using/ have you previously used any of the following? (Please tick):
Roaccutane: How long have you been using / did use Roaccutane? ________________________ Prescription Retin A: How frequent is your use? _____________ Where do you apply it? __________ Steroids or steroid creams: How frequent is your use? _____________
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
Please list any other allergies:
❑ Grapes ❑ Aloe Vera ❑ Aspirin
❑ Hair Dye ❑ Nuts
❑ Fragrance
_______________________________________________________________________________________ How do you heal from a cut? Brown pigment Pink then fades to white
Females Only
Are you (Please circle): Pregnant Lactating Trying to conceive
Are you taking any contraceptives or hormone supplements? Y / N
If yes, please specify: ________________________________________
LIFESTYLE
Do you participate in vigorous sports or aerobic activity? Y / N If yes, what type? ___________________ Do you follow a restricted diet? Y / N If yes, please specify: ____________________________________ Do you drink caffeine? Y/ N _______cups per week
Do you drink alcohol? Y / N ________ glasses per week
Have you had any recent sun exposure (including tanning booths)? Y / N
Do you smoke? Y / N
How would you rate your current stress levels : Low I Moderate IHigh IVery High
Client Signature: ___________________________ Consulting Skin Specialist: _________________________