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Dermalogica Consultation Form
Completing the form details below as fully as possible will help our therapy team to recommend the best products for your skin condition. All information is stored securely and is not shared with any other companies.
First Name
*
Surname
*
Email
*
Phone Number
Choose your Age Range
*
Under 21
21-30
31-40
41-50
51-60
60+
Do you currently have any medical conditions?:
*
Yes (Please Give Details)
No
Details of Current Medical Conditions:
List any medications, supplements, vitamins etc. that you take regularly:
Have you had any recent surgery ? (last 9 months):
Yes (Please give details)
No
Recent Surgery Details:
Do you smoke?:
Yes
No
Do you exercise regularly?:
Yes
No
Do you follow a restricted diet?:
Yes
No
Rate your level of stress:
Low Stress
Low-Medium Stress
Medium Stress
High Stress
Do you have any special skin problems pertaining to your face or body?:
Yes (Please give details)
No
Skin Problem Details:
What skin care products are you currently using on your Face (Select all that apply):
Soap
Cleanser
Toner
Moisturiser
Masque
Exfoliator
Eye Products
What skin care products are you currently using on your Body (Select all that apply):
Soap
Shower Gel
Scrubs
Oil
Body Moisturiser
Depilatory Products
Self Tanners
Have you ever had chemical peels, microdermabrasion or any resurfacing treatments?:
Yes
No
Do you use Accutane, Retin-A, Renova, Adapalene or other prescription skin products?:
Yes
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)
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?:
15
20
30
50+
Do you sunbathe or use sunbeds?:
Yes
No
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
Do you ever experience oily shine during the day?:
Yes
No
Occasionally
Do you ever experience skin breakouts?:
Yes
No
Occasionally
Do you drink more than 4 caffeinated beverages daily?:
Yes
No
Do you ever experience a burning, itching sensation on your skin?:
Yes
No
Have you ever had a reaction to any of the following?:
Cosmetics
Medicine
Iodine
Pollen
Food
Hydroxy Acids
Animals
Fragrance
Suncreams
(Females only) Are you pregnant or trying to become pregnant?:
Yes
No
(Males only) What is is your current shaving system?:
Electric
Blade
(Males only) Do you experience irritation from shaving?:
Yes
No
Occasionally
(Males only) Do you experience ingrown hairs?:
Yes
No
Occasionally
What are your skin care goals?:
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