Marie Reynolds London Skin Health Assessment Step 1 of 4 25% Name* First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email* Phone Number Do You Have Any Medical Health Conditions?*Yes, please provide further detailsNoThird ChoiceHealth Condition Info*Health Condition Info*In the last 12 months have you used any of the following? Not Applicable Antiobiotics - Oral or Topical Steroids - Oral or Topical Dr. Prescribed Retinoids Hormone Replacement Therapy Contraceptive Pill Acne Medication Blood Thinning Medication Any other medication please specify Tick all that applyOther Medication Info*Other Medication Info*Do you have any allergies (food, product, medication etc.)*YesNoAllergy Info*Have you had any reaction to a food, product or medication in the past?*YesNoReaction Info*Please indicate are you or do you have any of the following? None of these Pregnant Pacemaker Porphyria Diabetic Epilepsy Cardiac Irregularities Metal Plate/Pins Radiotherapy Chemotherapy Moles or Sun Spots Removed History Thrombosis/Embolism Circulatory Disorders Multiple Sclerosis Hearing Implants Tinitus Auto Immune Disorder Any other medical conditions - please specify Tick All That ApplyMedical Condition Info* Are you prone to any of the following?* Psoriasis Eczema/Dermatitus Rosacea Kerloid Scaring Hepres Simplex / Cold Sores Slow Wound Healing No Tick All That ApplyHow would describe your skin type?*NormalDryOilyCombinationWhat best describes your skin tone?*Very Fair - Always Burn, Never TanFair - Usually burns, tans with difficultyMedium - Sometimes burns, slow tanningMedium Olive - Rarely burns, fast tanningDark - rarely burns, tans easy and fastVery Dark - Never burns, tans easilyWhat are your main skin concerns?* Clogged Pores / Black Heads Acne / Blemishes Sensitivity Redness Rosacea Dehydration Loss of Tone / Loose Skin Lines / Wrinkles Large Pores Scarring Brown Spots / Discoloration Lack of Radiance Other (Please Specify) Your Other Skin ConcernWhat area on your skin is your main concern?* Forehead Eye Area Cheeks Nose Jaw Line Chin Neck Body Other (Please Specify) Your area of skin concern?*What age bracket best describes you?* Under 18 18-25 25-34 35-44 45-54 55-64 65+ How would you rate the firmness of your skin? How would you rate your skin sensitivity? Please indicate if you have had any of the following?* Microneedling IPL Laser Treatments Micro Dermabrasion Fraxel Anti Wrinkle Injections / Botox Dermal Fillers - face or lips Chemical Skin Peels None of the Above Any other skin treatments (please specify) Other skin treatments you have recieved* Are you currently taking any supplements?*Yes (Please Specify)NoWhat supplements do you take?*Do you have any dietry restrictions?*YesNoWhat dietry restirctions do you have?*How would you rate your current level of stress? How many hours of sleep do you get per night?*Is this sleep broken?*YesNoHave you any of the following digestive issues?* IBS Crohns Disease Constipation None of the above Other (Please Specify) Do you have regular bowel movements?*YesNoIs your cycle regular?*YesNoAre you prone to thrush or candida infections?*YesNoHow is your energy level? How is your mental performance; concentration, forgetful, brain fog? What digestive issue do you have?*What time do you last eat at night?*How would you rate your work-life balance? Upload images of your skin Drop files here or Accepted file types: jpg, jpeg, png.