SkinPen Consultation

Where * denotes a required field.

    Patient Profile

    Age Group: *

    Lifestyle: *

    Patient Assessment

    Contra-indications that prevent treatment – (Select if/where appropriate):

    Contra-indications that restrict treatment – (Select if/where appropriate):

    Personal Information

    Have you had any health problems in the past or present? *

    Have you been under the care of a medical practitioner or other healthcare specialist in the last year? *

    Are you currently using any prescription medications (oral or topical)? *

    Are you currently using any supplements or herbal remedies (oral or topical)? *

    Do you suffer from anxiety, stress, depression and/or are clinically diagnosed? *

    What are your stress levels at home? (0 - 10 where 10 is highest) *

    What are your stress levels at work? (0 - 10 where 10 is highest) *

    Do you smoke? Have you smoked in the past/present? *

    Do you drink alcohol? *

    Are you trying to conceive, pregnant or lactating? *

    Are you?

    Do you have any allergies? *

    Are you currently sun/wind burnt? *

    Do you wear a sun protectant? *

    Do you suffer from Herpes simplex? (if yes take HS medication 5 days pre/post treatment) *

    Have you had any of the following within the last 1-4 weeks?

    Have you used any home care products containing any of the following in the last 3 days?

    What is your current daily skincare regime A.M and P.M? Please list any and all products you use