Online Skin Consultation

Name

Email Address

Your Age

Address (City, State, Postcode)

Describe your concern

Briefly describe any changes you have noticed in your skin, especially as a teen, under stress, when pregnant or when travelling.

Are you pregnant or considering being so? Are you pregnant or considering being so? Yes No

Are you breastfeeding? Are you breastfeeding? Yes No

Do you suffer from a chronic illness? Do you suffer from a chronic illness? Yes No

Are you currently on any medications? Including any vitamins/ supplements? Are you currently on any medications? Including any vitamins/ supplements? Yes No

how much do you drink water per day

how much do you drink tea per day

how much do you drink herbal tea per day

how much do you drink coffee per day

how much do you drink alcohol per day

Do you smoke? Do you smoke? yes no

Are you vegetarian or vegan? Are you vegetarian or vegan? Vegetarian Vegan Neither

Do you eat healthily? Do you eat healthily? yes no

How many times a week do you eat red meat?

How many times a week do you eat fish?

How many times a week do you eat leafy greens?

How much time per day do you spend outside?

Do you exercise regularly? Do you exercise regularly? yes no

How often do you have a peel, microdermabrasion or chemical facial? How often do you have a peel, microdermabrasion or chemical facial? Never Not often Monthly 3-6 monthly 6-12 monthly

Are you currently using or have used previously topical retinols or Ro-Accutane? Are you currently using or have used previously topical retinols or Ro-Accutane? Yes - Currently using Yes - Used in the past No

Do you have any form of injectables e.g. anti-wrinkle injections? Do you have any form of injectables e.g. anti-wrinkle injections? yes no

Have you ever used a product which has caused a reaction you haven’t liked? If so, please describe even if you can’t remember the product – maybe the type of place you purchased it from.

What is your current MORNING & EVENING skin care routine? Include the brands please.

Do you use sunless tanning products? Do you use sunless tanning products? yes no

Do you use makeup? Do you use makeup? yes no