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Environ Skin Consultation
Personal Details
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
County / State / Region
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Afghanistan
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Virgin Islands, U.S.
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Date of Birth
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Skin Questionnaire
Welcome to Healthy Skin
Please answer the following Health questions
Are you prone to any of the following?
Select All
Psoriasis
Eczema/Dermatitis
Rosacea
Keloid Scarring
Herpes Simplex
Comedones / Blackheads
Pustules/Whiteheads
Cystic Acne
Occasional Spots
Hormonal Breakouts
Never Breakout
If yes, where and how long?
*
Do you have a history of the following?
Sunbeds
Smoking
None of the above
What is your skin type?
Dry (Dull, Flaky)
Oily (Breakouts, Blackheads, Shiny)
Combination (Dry Cheeks, Oily T-Zone)
Normal (Balanced,Smooth)
How sensitive is your skin?
Not Sensitive
Mild
Moderate
Very Sensitive
What are your main skin concerns?
Roseacea
Uneven Skin Tone
Acne
Pigmentation
Scarring
Fine Lines
Wrinkles
Please indicate are you or do you have any of the following
These conditions are contraindicated to the Environ® DF Ionzyme® electrical treatments. + These require doctors consent
Select any which apply to you
*
Select All
Pregnant
Pacemaker
Porphyria
Diabetic
Epilepsy
Cardiac Irregularities
Metal Plates/Pins
Radiotherapy
Chemotherapy
Thrombosis/Embolism
Circulatory Disorders
Moles or Sun Spots Removed
Multiple Sclerosis
Any other medical conditions
*
Yes
No
Please specify
*
Any known allergies
*
Yes
No
Please specify
*
Sonophoresis Caution
Do you have any of the following?
*
Select All
Hearing Implants
Tinitus
Have you been treated with any of the following?
Select any that apply
*
Select All
Hormone Replacement Therapy
Bioidentical Hormone Replacement Therapy
Contraceptive Pill
Topical Corticosteroids
Oral Corticosteroids
Topical Antibiotics
Oral Antibiotics
Topical Vitamin A (Retin A)
Roaccutane
Acne Medication
Blood Thinning Medication
Any other medication
*
Yes
No
Please specify
*
If you have answered yes, please indicate when and for how long
*
Please indicate if you are having or have had any of the following
CST
*
(immediately after treatment)
Yes
No
IPL
*
(immediately after treatment)
Yes
No
Laser Treatments
*
(wait 2 weeks)
Yes
No
Microdermabrasion
*
(immediately after treatment)
Yes
No
Electrolysis
*
(wait 2-3 days)
Yes
No
Facial Waxing
*
Yes
No
Botox
*
(wait 2 weeks)
Yes
No
Fillers
*
(consult practitioner)
Yes
No
Other skincare treatments
If you have answered yes, please indicate when and for how long
*
Your Environ Regime
Please feel free to upload photos of your skin, in particular any problem areas
Drop files here or
What is your current skincare routine? Please indicate which products you are currently using.
*
What is it that you would like to achieve with your skin?
Once you submit this information your therapist will be in contact with you to take you through the next steps.
To submit this form, you need to accept our Privacy Statement
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