(08) 9300 0643
hello@rochebeautycurated.com
Shop 5 Carramar village, Cheriton drive, Carramar WA 6031

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- Online Consultation

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Online Consultation Questionnaire

First Name

Last Name

Date of Birth

Mobile/Cell

Email

Address

Suburb

State

Postcode/ZIP

Occupation

How would you like your skin to look and feel?

Please advise if you are taking any prescribed medications e.g.: Isotretinon, Warfarin, Chemotherapy medication, thyroid, contraceptive pill, HRT

Please advise if you are taking any non-prescribed medication or supplements e.g.: Ibuprofen, Asprin, Fish oil

Please advise of any known allergies:

Are you pregnant or trying or lactating?

Do you have any of the following conditions?

Diabetes Keloid Scars Skin Scars Autoimmune Disease Cold Sores Haemophilia Do you smoke Do you wear contacts

Stress Levels - Please rate between 1 (lowest) to 5 (highest) your current level

What is your current exercise routine and frequency?

Your current skincare at home. Please check all that apply

Cleanser Serum SPF Moisturiser Exfoliator Mask

Skincare brand used currently

Please select all that are applicable to you

Autoimmune disease, diabetes, kidney disease and excessive smoking may increase healing and recovery time Roaccutane in the last 6 months Blood thinning medications Cold sores Psoriasis, eczema, dermatitis visible Pregnant, trying to fall pregnant or lactating Stress levels Treatment for cancer History of poor healing or keloid scarring Medical diagnosis of rosacea Post skin trauma, discolouration Recent surgery (within 12 months) Recent skin cancer removal Open wounds Recent sun burn Laser or IPL within the last 2 weeks Recent treatments within 2 weeks Injectables within 72 hours Facial waxing, electrolysis or use of depilatory creams within 5 days Commitment to daily use of SPF protection

What are the colour of your eyes?

Light blue or green, grey Blue, green, grey Dark blue or green, light brown (hazel) Dark Brown Brownish Black

What is the colour of your hair (naturally and before raging)?

Red Blonde Chestnut or dark blonde Dark brown Black

What is the colour of your skin (unexposed areas)?

Pink Very pale Light brown or olive Brown Dark brown

Do you have freckles on unexposed areas?

Many Several Few Rare None

What happens to your skin if you stay in the sun for an extended period?

Severe burns, blistering, peeling Moderate burns, blistering, peeling Burns sometimes followed by peeling Rare burns No burns

Do you turn brown after sun exposure?

Never Rarely Sometimes Often Always

How brown do you get?

Hardly or not at all Light tan Medium tan Dark tan Very dark tan

Is your face sensitive to the sun?

Very sensitive Sensitive Mildly sensitive Resistant Very Resistant

How often do you tan?

Never Rarely Sometimes Often Always

When did you last expose your skin to the sun or artifical tanning sources (tanning beds)?

More than three months ago In the last 2-3 months In the last 1-2 months In the last week In the last day

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Shop 5 Carramar village, Cheriton Dr, Carramar WA 6031

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(08) 9300 0643
hello@rochebeautycurated.com

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