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Contact Details
Name
Email
Phone Number
Date of Birth
Address
1. PLEASE ANSWER THE FOLLOWING HEALTH QUESTIONS:
Are you prone to any of the following? Psoriasis YesNo Eczema/Dermatitis YesNo Rosacea YesNo Keloid Scarring YesNo Herpes Simplex YesNo
If you are, where and how long?
Please indicate, are you or do you have any of the following? Pregnant YesNo Pacemaker YesNo Porphyria YesNo Diabetic* YesNo Cardiac Irregularities* YesNo Metal Plate/Pins YesNo Radiotherapy* YesNo Chemotherapy* YesNo Moles or Sun Spots Removed* YesNo History Thrombosis/Embolism* YesNo Circulatory Disorders* YesNo Multiple Sclerosis* YesNo
These conditions are contraindicated to the Environ® DF Ionzyme® electrical treatments. *These require doctors consent
Any other medical conditions? YesNo
Any known allergies? YesNo
Sonophoresis Caution:
Hearing implants YesNo Tinitus YesNo
Have you been treated with any of the following? Hormone Replacement Therapy YesNo Bioidentical Hormone Replacement Therapy YesNo Contraceptive Pill YesNo Topical Corticosteroids YesNo Oral Corticosteroids YesNo Topical Antibiotics YesNo Oral Antibiotics YesNo Topical Vitamin A (Retin A) YesNo Roaccutane YesNo Acne Medication (e.g. Benzoyl Peroxide, Azelaic Acid, Alpha Hydroxy Acids)YesNo Blood Thinning Medication (e.g. Warfarin) YesNo
Any other medication? YesNo
If you have answered yes to any of the above, please state when and how long for:
Please indicate if you are having or have had any of the following:
CST (Immediately after treatment)YesNo IPL (Immediately after treatment)YesNo Laser Treatments (Wait 2 weeks)YesNo Microdermabrasion (Immediately after treatment)YesNo Electrolysis (Wait 2-3 days)YesNo Facial Waxing YesNo Botox (Wait 2 weeks)YesNo Fillers (Consult Practitioner)YesNo
Other skincare treatments:
If you have answered yes to any of the above, please state when and where:
2. YOUR CONCERNS AND SKIN TYPE: Tell us - what are your main concerns?Tick all that apply. Lines & Wrinkles Dark Spots Eye Area Dryness/Dehydration Firming/Lifting Redness/Sensitivity Sun Damage Visible Pores Lack of Radiance Scarring/Texture Oil Control Blemish Prone
Please tell us where on your face you are noticing these concerns:
Tell us which vitamins and supplements you take, and do you take any for your skin?
Skin Care and Make-up Routine Please tick if you use the products, and then specify which brand and products you use.
Eye Make-up Remover
Pre-Cleanser
Cleansers & Toners
Exfoliators/Masks
Eye Products
Serums
Moisturisers
Sun Protection
Body Lotions
Treatments/Facials
Foundation
Eye Make-Up
Cheek Make-Up
Lips
3. YOU AND YOUR LIFESTYLE How do your cheeks look/feel? Dry Sensitive Comfortable Shiny Oily
How does your T-Zone look/feel? Dry Sensitive Comfortable Shiny Oily
How does your Eye Area look/feel? Dark Circles Lines/Wrinkles Puffiness Firming/Lifting Sensitive
Describe the environment that your skin lives in.Tick all that apply. Urban Frequent Travel Suburban Office Outdoor Activities Air Conditioning
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 4 Hours 5 Hours 6 Hours 7 Hours 8 Hours or More
How would you describe your stress levels? Very Low Low Moderate High Very High
Tell us about your diet and lifestyle.
Oily Fish:
Fruit & Veg:
Water Intake:
Nuts & Seeds:
Refined Sugar:
Are you a Smoker? YesNo
Tea/Coffee:
Alcohol:
Do you follow any diets? YesNo
Are you Vegetarian? YesNo
Are you Vegan? YesNo
Do you currently Breast Feed? YesNo
4. LET'S RECAP:
Your main concern is:
Your skin type is:
Your skin goals are:
We recommend you take some photos of your skin so that you can see the before and after effect.
Your Personal Information
Except for where you have separately granted KVL SKN permission to store and process your before and after photographs and face scan data, KVL SKN itself does not store or process your other personal and medical data as captured in this form - 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 I HAVE SUPPLIED IN THIS FORM IS RELEVANT AND FACTUALLY CORRECTI agree*
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