DermaPure+ Consultation Form NamePhone NumberAddressPostcodeEmail AddressDate of Birth (YYYY-DD-MM)Clinic NameClinic NumberClinic AddressClinic PostcodeOccupationStress Level (1-5, 1 being not stressed, 5 being very stressed)How many times a week do you exercise?How many glasses of water do you drink a day?Do you have a balanced diet?Do you drink alcohol? If yes, how many units a week?Do you smoke? If yes, how many a day?Do you drink caffeine? If yes, how much a day?Recent sun exposure? This includes sun bedsSkin ConcernsAcne and/or Acne ScarringRedness/RosaceaSkin SensitivityPhoto damage/PigmentationBlocked Pores/BlackheadsDull SkinFine Lines, Wrinkles, Loss of ElasticityImprove Skin TextureOily, combination, congested skinDry, Dehydrated SkinAre you currently using Benzoyl Peroxide, AHA’s or BHA’s?What is your current skin care routine?Have you ever had any anti wrinkle injections, fillers, Chemical peels or laser treatments? If so when?Do you use the below?CleanserTonerMaskExfoliatorSPFSerumsAny other products not listed above?-1Are you under a physician’s care for any medical condition?YesNoBeing treated for any medical condition?YesNoCurrently using Steroids or steroid cream products?YesNoTaking any medications/Natural Remedies?YesNoPlease list any medications/Supplements you are taking below:Hydroquinone - if so when?Retin A - if so when?Accutane/Isotretinoin - if so when?Blood Thinning MedicationsDo you have any allergies?YesNoHave you had any allergic reactions to any medications? If yes what type?Have you had any adverse or allergic reactions to any cosmetic products, foods, clothing, soaps, shampoos, hair dyes, perfumes, or jewellery?YesNoPlease advise anything else that has not been listed above?Do you have any of the following?Hormonal Imbalance e.g. Endometriosis/polycystic ovaries syndrome/other?Burns/Grafted SkinEpilepsyKidney DiseaseShinglesEczemaPsoriasisDermatitisThyroid ConditionKeloid Scar FormationHypertrophic Scar FormationAsthmaA Heart ConditionThrombosisHigh Blood PressureMetal ImplantsHaemophiliaDiabetes?YesNoIf Yes, which type?Type 1Type 2Cold SoresYesNoIf Yes, are they reoccurring?YesNoTattoos or permanent makeup in the area to be treated?YesNoHave you ever had cancer with a history of radiation treatments?YesNoDo you currently receive radiation treatments?YesNoHave you ever been diagnosed with melanoma or any form of skin cancer?YesNoAre you?PregnantBreastfeedingContraceptivesTaking any hormone supplementsClient NameDate(YYYY-MM-DD)Submit
