Perfect Skin Direct: Online Skin Care Consultations

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Contact Details
Name:
Address:
Phone:^*
Email:
Age:	Under 21 21-30 31-40 41-50 51-60 60+
Your health
Within the last year, have you been under a physician's care?	Yes No
Within the last year, have you been under a dermatologist's care?	Yes No
Within the last nine months, have you undergone any surgery?	Yes Specify: No
Have you had any of these health problems in the past or present?	Cancer Diabetes Epilepsy Heart problem Hormone imbalance Spinal injury Hysterectomy Thyroid condition Varicose veins Systemic disease
List medications, supplements, vitamins, diuretics, slimming tablets etc. that you take regularly:
Do you smoke?	Yes No
Do you follow a restricted diet?	Yes No
Do you have regular sleep patterns?	Yes No
Do you wear contact lenses?	Yes No
Do you have metal implants or a pacemaker?	Yes No
Your Skin
With what temperature of water do you cleanse?	Cool Warm Hot
Do you have any special skin problems pertaining to your face or body?	Yes Specify: No
What skin care products are you currently using?	Soap Cleanser Toner Moisturiser Masque Exfoliator Eye products Others
Exfoliation History
Have you ever had chemical peels, laser, microdermabrasion or any resurfacing treatments?	Yes No
In the last month?	Yes No
Do you use Accutane, Retin A, Renova or Adapalene?	Yes No
In the last 3 months?	Yes No
Do you use an acne medication?	Yes No
In the last 6 months?	Yes Specify: No
Are you currently using any products that contain the following ingredients?	Glycolic acid Lactic acid Any exfoliating scrubs Any hydroxy acid product Vitamin A derivatives (i.e. retinol)
Moisture Hydration
How much plain water do you consume daily?
How many alcoholic beverages do you consume weekly?
Do you ever experience these conditions on your skin?	Flakiness Tightness Obvious Dryness
What spf sunscreen do you use on your face?
What spf sunscreen do you use on your body?
Do you sunbathe and/or use tanning beds?	Yes No
Capillary Activity
Do you burn easily in moderate sunlight?	Yes No
Do you blush easily when nervous?	Yes No
Do you have a tendency to redness?	Yes No
Do you suffer from sinus problems?	Yes No
Oil Secretion
Do you ever experience oily shine during the day?	Yes No Occasionally
Do you ever experience skin breakouts?	Yes No Occasionally
Nerve Activity
Do you drink caffeinated beverages?	Yes Daily: No
Do you ever experience a burning, itching sensation on your skin?	Yes No
What is your pain threshold?	Low Medium High
Have you ever had a reaction to any of the following?	Cosmetics Medicine Iodine Pollen Food Hydroxy acids Animals Fragrance Sunscreens
Female Clients Only
Are you taking oral contraception?	Yes No
Are you pregnant or trying to become pregnant?	Yes No
Are you lactating?	Yes No
Male Clients Only
What is your current shaving system?	Electric Shave Wet Shave
Do you experience irritation from shaving?	Yes No
Do you experience ingrown hairs?	Yes No
Your Skin Goals:
Additional Comments:
What does
equal?

Online Skin Care Consultations

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