CONFIDENTIAL SKIN HEALTH QUESTIONNAIRE

CONFIDENTIAL SKIN HEALTH QUESTIONNAIRE

Please complete this form adding details of current skincare products. This form pays for the consultation which is redeemed against products purchased or treatments over £100 - no other fee is charged against your registered card. Please book an appointment time for the consultation from DianeNivern.com or call us on 01617961169
Take Photo - Please take a clear, well lit portrait picture of your face, without make up
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City County

Post Code
MOBILE *
EMAILADDRESS *
DATE OF BIRTH *

Day Month Year
Date
Age at time of consultation *
How did you hear about us? *
Web search what did you search for ? / Recommendation from who? / Instagram / Facebook / other?
OCCUPATION *
This gives me insight into how your skin may be affected by your occupation
LIST OF ALL ALLERGIES *
What would you like to achieve by seeking professional skincare treatments & advice? *
Please give me an idea of what help you’re looking for
DESCRIBE YOUR SKIN TYPE *

NORMAL DRY/DEHYDRATED OILY ACNE/ACNE PRONE ROSACEA SENSITIVE / REACTIVE
How would you like your skin to change ? *

More hydrated / less dryness Less oily Reduce pore size Fewer spots Less redness Smoother texture Brighter even toned skin Reduce lines & wrinkles Eliminate blackheads / bumps under skin Reduce acne scarring / fade spot marks Slow to heal spots Other
I'd like you to feel and stroke your face - does it feel smooth, rough, patchy, puffy, oily, hot, tight or flaky anywhere? *
Gender

Male Female Other
How do you feel about your skin & appearance? *
Have you been treated for: *

ACNE DEPRESSION / ANXIETY SKIN DISEASE COLD SORES DIABETES CANCER ECZEMA / DERMATITIS Other
Have you had facial treatments before? What treatments? *
Where you happy with results, any reactions or comments?
Which describes you best? *

Type 1: ‘No Wrinkles’ Early skin-aging Mild pigment changes Minimal wrinkles No ‘age spots’ Type 2: ‘Wrinkles in Motion’ Patient age: 30s to 40s Early to moderate visible ageing, Appearance of lines only when face moves, Early brown ‘age spots’, Skin pores more prominent, Early changes in skin texture Type 3: ‘Wrinkles at Rest’, Advanced visible ageing, Prominent brown pigmentation, Visible brown ‘age spots’, Prominent, visible thread veins, Wrinkles present with face at rest Type 4: ‘Only Wrinkles’, Severe visible ageing, Wrinkles everywhere, at rest or moving Yellow-gray skin colour Prior skin cancers Pre-cancerous skin changes
DO YOU / HAVE YOU SMOKED? DO YOU VAPE? *
Do you have any significant health / medical history? *
DO TAKE ANY MEDICATION INCLUDING THE PILL? *
What medication?
ARE YOU PREGNANT? TRYING TO GET PREGNANT? HRT? IVF? *
YOUR CURRENT LEVEL OF STRESS: (1 least to 10 most) *
YOUR NORMAL LEVEL OF STRESS: (1 least to 10 most) *
WHEN YOU GO OUT INTO THE SUN DO YOU: *

ALWAYS BURN (I) USUALLY BURN (II) SOMETIMES BURN (III) RARELY BURN (IV) VERY RARELY BURN (V) NEVER BURN (VI)
Please describe your ethnic background / skin colour
This helps me to understand your skin's characteristics for suitable treatments & products
Do you SUNBATHE or use TANNING BEDS or have done in the past ? *
ARE YOU PLANNING A HOLIDAY WITH SUN EXPOSURE SOON?
HOW WOULD YOU DESCRIBE YOUR DIET? *

Regularly eat fruit & veg? Regularly eat meat / fish? Milk / Cheese? Vegetarian / Vegan? Take Aways / Ready meals?
How much alcohol do you drink per week? *
HOW MUCH WATER DO YOU DRINK A DAY? *

UNDER A LITRE A LITRE OVER A LITRE
Have you had treatment from any of the below, if yes what did you have? :

DERMATOLOGIST PLASTIC SURGEON AESTHETICIAN FACIAL HAIR REMOVAL laser / wax / threading? Other
How much time / involvement can you commit to your skincare routine? *

Dedicated / Multi step programme day & night Could manage a simple day & night routine Often forget to take make up off Other
WHAT SKINCARE PRODUCTS / BRANDS ARE YOU CURRENTLY USING? *
How do you clean your skin, what other products do you use , how often?
DO YOU USE A DAILY SUNSCREEN PROTECTION PRODUCT? WHICH FACTOR? *
DO YOU EXERCISE? IF SO HOW OFTEN
What types of exercise?
Rank in order of importance your priorities 5 being most important to 1 Least important
REDUCTION OF FINE LINES
ACNE SCARS DIMINISHED
REDUCTION OF BROWN SPOTS/SUN DAMAGE
REDUCTION OF REDNESS
REDUCTION OF OIL/ACNE
Are you considering treatments for ?

Wrinkle relaxing injections (botox)? Dermal Fillers for lips Dermal Fillers for facial contours / lines / cheeks / jawline Skinboosting for skin quality, hydration, firmness, radiance? Eyelid lifting / Eye bag smoothing Blemish removal / skin tags, cherry angiomas, age spots Would you like information on these treatments?
Thank you for completing my questionaire.

Your answers will help me to understand your skin's needs to design the most appropriate in-clinic treatments with supporting home skincare routine.

I look forward to meeting you soon

Diane Nivern
Booking Fee: *

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GBP Payment reserves your booking for a Virtual Online Consultation - fee is redeemable against purchases of our recommended products over £100 or from future treatments. Booking fee is retained by Diane Nivern Clinic Ltd if you’re not contactable to attend your booked online consultation.
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DATE: *

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Date
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CONFIDENTIAL SKIN HEALTH QUESTIONNAIRE

Rank in order of importance your priorities 5 being most important to 1 Least important