Chique Online Skin Consultation Form

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone Number *

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Are you prone to any of the following? *

If none please select "None of the above"

Psoriasis

Eczema/Dermatitis

Rosacea

Keloid scarring

Herpes Simplex

None of the above

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 If none please select "None of the above"

Pregnant

Pacemaker

Porphyria

Diabetic*

Epilepsy*

Cardiac Irregularities*

Metal Plate/Pins

Radiotherapy*

Chemotherapy*

Moles or Sun Spots Removed*

History Thrombosis/Embolism*

Circulatory Disorders*

Multiple Sclerosis*

None of the above

Sonophoresis Caution: *

If none please select "None of the above"

Hearing implants

Tinitus

None of the above

Have you been treated with any of the following? *

If none please select "None of the above"

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 (e.g. Benzoyl Peroxide, Azelaic Acid, Alpha Hydroxy Acids)

Blood Thinning Medication (e.g Warfarin)

None of the above

Please indicate if you are having or have had any of the following *

If none please select "None of the above"

CST (Immediately after treatment)

IPL (Immediately after treatment)

Laser Treatments (Wait 2 weeks)

Microdermabrasion (Immediately after treatment)

Electrolysis (Wait 2-3 days)

Facial Waxing

Botox (Wait 2 weeks)

Fillers (Consult Practitioner)

None of the above

Tell me what are your main skin concerns? *

If none please select "None of the above"

Lines and wrinkles

Dark spots

Eye area

Dryness/dehydration

Firming/lifting

Redness/sensitivity

Sun damage

Visible pores

Lack of radiance

Scarring/texture

Oil control

Blemish prone

None of the above

Describe the environment that your skin lives in *

If none please select "None of the above"

Urban

Outdoor Activities

Frequent Travel

Air Conditioning

Suburban

Office

None of the above

What kind of sun exposure do you get? *

Very Low (Incidental exposure from walking)

Low

Moderate

High

Very High (Extended Exposure from being outside

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

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