Skin Insights FormHome > Skin Insights FormSKIN INSIGHTS FORMName*Date* DD slash MM slash YYYY Do you have any known allergies? If so, please list:* Yes NoKnown allergiesWhich of the following is true of your skin type:* Always burn, never tan Burn moderately, tan gradually Usually burn, tan with difficulty Always tan, rarely burnWhat is your current skin care regime:CleansersMoisturiserTonerSerumsExfoliationAre you pleased with the results of your current skin care routine? Yes I love my skin I’d like my skin to be betterPlease tick which of the following (if any) apply to you: Arthritis Asthma Nervous/Psychotic conditions Contact lenses Glaucoma Cataracts Haemophilia or other clotting disorder Herpes or coldsores Keloid scars Thyroid abnormalities EpilepsyAny metal pins or plates Any metal pins or platesLocations of pins and platesCardio-vascular conditions Cardio-vascular conditionsCardio-vascular conditionsContagious or infectious diseases (in past 3 mths) Contagious or infectious diseases (in past 3 mths)Specified diseasesDiabetes DiabetesType of diabetesCancer CancerType of cancerSkin pigment conditions Skin pigment conditionsSkin pigmentation detailsPrevious treatments on area (please select if/where appropriate): Cosmetic Surgery Microdermabrasion Traditional TattooCosmetic Tattoo Cosmetic TattooCosmetic tattoo locationFiller or Injectables Filler or InjectablesFiller and injectables locationAny reaction to previous treatment:* Yes NoList of reactions to previous treatmentsAny surgery/operations on the last 12 months:Are you planning any surgery in the near future:Do you have any special events coming (we keep these in mind in terms of downtime or recovery):List any medications or herbal remedies you are taking:Are you currently pregnant:* Yes NoAre you suffering from any other medical conditions that are not listed above - or is there anything else we should know that may affect your treatment?This is a true and accurate statement of my medical history, past and present. I am aware that failure to disclose information pertinent to my treatment could have serious health ramifications. I am also aware that failure to disclose information pertinent to my treatment could have direct bearing on treatment outcome. ** This is a true and accurate statement of my medical history, past and present. I am aware that failure to disclose information pertinent to my treatment could have serious health ramifications. I am also aware that failure to disclose information pertinent to my treatment could have direct bearing on treatment outcome.
