Name * First Name Last Name Date * MM DD YYYY Email * Date of Birth MM DD YYYY When was you last Covid of Flu Vaccine? MM DD YYYY Phone * (###) ### #### Welcome to your online skin consultation Do you suffer from or have suffered from any of the following conditions in the past 3 months? Psoriasis * Yes No Eczema/Dermatitis * Yes No Rosacea * Yes No Keloid scarring * Yes No Herpes Simplex * Yes No If you are, where and how long? 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. Pregnant * Yes No Pacemaker * Yes No Porphyria * Yes No Epilepsy * Yes No Diabetic * Yes No Metal Plate/Pins * Yes No Cardiac Irregularities * Yes No Chemotherapy * Yes No Radiotherapy * Yes No Moles or Sun Spots Removed * Yes No History of Thrombosis/Embolism * Yes No Multiple Sclerosis * Yes No Circulatory Disorders * Yes No Any other medical conditions Please specify Any known allergies Please specify Before Sonophoresis Therapy let us know if you have any of the following: Hearing implants * Yes No Tinitus * Yes No Have you been treated with any of the following? Hormone Replacement Therapy * Yes No Contraceptive Pill * Yes No Topical Corticosteroids * Yes No Oral Corticosteroids * Yes No Bioidentical Hormone Replacement Therapy * Yes No Oral Antibiotics * Yes No Topical Antibiotics * Yes No Topical Vitamin A (Retin A) * Yes No Roaccutane * Yes No Acne Medication * Yes No Blood Thinning Medication * Yes No Any other medication Please specify If you have answered yes, please indicate when and for how long Please specify Please indicate if you are having or have had any of the following: Collagen Stimulation Therapy (CST) * (Immediately after treatment) Yes No Intense Pulsed Light Therapy (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 and If you have answered yes, please indicate when and where YOUR CONCERNS AND SKIN TYPE Tell us what are your main concerns? Lines and Wrinkles Yes Dark spots Yes Eye area Yes Dryness/dehydration Yes Redness/sensitivity Yes Sun damage Yes Visible pores Yes Lack of radiance Yes Scarring/texture Yes Oil control Yes Blemish prone Yes Tell us which vitamins and supplements you take? Do you take any for your skin? TELL US MORE ABOUT YOUR MAKE-UP ROUTINE Please select those that apply Eye Make Up Remover Pre-Cleanser Sun Protection Treatments / Facials Foundation Cheeks Exfoliators / Masks Eyes Moisturisers Body Lotion Serums Eyes Lips TELL US ABOUT YOUR SKIN How do your cheeks look and feel? How does your T Zone look and feel? * Dry Sensitive Comfortable Shiny Oily How does your eye area look and feel? * Dry Sensitive Comfortable Shiny Oily Describe the environment that your skin lives in: * Urban Frequent Travel Surburban Office Outdoor Activities Air Conditioning YOU AND YOUR LIFESTYLE What kind of sun exposure do you get? * Very Low Low Moderate High Very High On average how many hours of sleep do you get a night? * Less than 4hrs 5hrs 6hrs 7hrs 8hrs or more How would you describe your stress levels? * Very Low Low Moderate High Very High Tell us about your diet & lifestyle Oily Fish (per week) Fruit & Veg (per day) Water Intake (per day) Refined Sugar (per day Smoker (per day) Tea & / or Coffee (per day) Alcohol (per week) Nuts & Seeds (per week) Vegetarian Diet Vegan Breast Feeding LET’S RECAP Your main concern is: * Your skin type is: * Your skin goals are: * Your Personal Information Except for where you have separately granted iiaa permission to store and process your before and after photographs and face scan data, iiaa itself does not store or process your other personal and medical data as captured on this record card - please liaise with the salon direct to understand its arrangements for data security and compliance with data legislation. TO THE BEST OF MY KNOWLEDGE THE MEDICAL INFORMATION IS RELEVANT AND FACTUALLY CORRECT. Thank you for completing this part of the Free Online Consultation. We will be in touch shortly. Free Online Skin Consultation
