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Skin Health Assessment
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Name
*
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
US Minor Outlying Islands
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Email
*
Phone Number
Do You Have Any Medical Health Conditions?
*
Yes, please provide further details
No
Third Choice
Health 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 apply
Other Medication Info
*
Other Medication Info
*
Do you have any allergies (food, product, medication etc.)
*
Yes
No
Allergy Info
*
Have you had any reaction to a food, product or medication in the past?
*
Yes
No
Reaction 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 Apply
Medical 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 Apply
How would describe your skin type?
*
Normal
Dry
Oily
Combination
What best describes your skin tone?
*
Very Fair - Always Burn, Never Tan
Fair - Usually burns, tans with difficulty
Medium - Sometimes burns, slow tanning
Medium Olive - Rarely burns, fast tanning
Dark - rarely burns, tans easy and fast
Very Dark - Never burns, tans easily
What 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 Concern
What 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)
No
What supplements do you take?
*
Do you have any dietry restrictions?
*
Yes
No
What 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?
*
Yes
No
Have you any of the following digestive issues?
*
IBS
Crohns Disease
Constipation
None of the above
Other (Please Specify)
What digestive issue do you have?
*
What time do you last eat at night?
*
How would you rate your work-life balance?
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