Virtual In-Depth Assessment.Let me help you with a plan to treat your skin-care concerns. Name * First Name Last Name Email * Phone Number Best way to get in touch Phone Email Date of Birth * MM DD YYYY How did you hear about Lili's? Occupation Your Health This file will be kept COMPLETELY confidential. It is essential to answer the questions correctly to receive treatments adapted to your needs by considering your skin's peculiarities and health. Agree? What products are you currently using on your skin? Do you have any allergies or intolerances? Do you have any of the following: Metallic Inclusions Copper IUD Metal Implant/Rod/Plate/Pins Did you have surgery in the last 9 months? If so, what was it for? Are you taking any of the following: Antibiotics Anti-inflammatory Antidepressants Anticoagulants Cortisone Accutane Steroids Skin topical medication cream Skin topical medication gel Other medication? Have you ever experienced any of the following conditions? Acne Claustrophobia Eczema Burns/Skin Graft Spasmophilia Epilepsy/Seizures Other dermatosis Do any of these apply to you? Pregnant Breastfeeding Trying to get pregnant Menopausal Taking hormonal contraceptives Type 1 diabetes Celiac disease Lupus Multiple Sclerosis Rheumatoid arthritis Heart disease/pacemaker/defibrillator Other diseases recognized or presumed Have you ever had laser resurfacing? Yes NO Have you ever had botox, collagen injections, or hyaluronic acid injections Yes No Have you ever had medical dermabrasion? Yes No Have you ever had microdermabrasion? Yes No Have you ever had a peel? Yes No Have you ever had cosmetic surgery? Yes No What brand of sunscreen do you wear? Do you smoke? If so, how many cigarettes per day? Which of the following applies to you: You sunbathe You use a tanning bed You never wear sun protection You wear sun protection sometimes You wear sun protection often You wear sun protection always Your skin heals quickly Do you have a daily skincare routine? What products do you use? What are your skincare goals? Maintain and improve skin firmness Even out skin tone Minimize lines and wrinkles Reduce redness Treat spots and pimples Reduce enlarged pores Reduce pigmentation Improve acne Minimize acne scarring Reduce broken capillaries Reduce age-spots Improve hyperpigmentation Reduce surgical/facial scars I don't know/none of the above Do you experience skin sensitivities? Superficial veins Redness and/or irritation Eczema Rosacea Inflamed acne Generally sensitive No, my skin is not sensitive How does your skin feel after you have washed it? Dry Normal Mixed Oily How does your skin feel during the day? Very dry and taut Quite dry Shiny on the forehead, nose and chin Oily Neither dry nor oily Are you under treatment for any current skin condition? Yes No What is your stress level? High Medium Low Do any of the following cause you to blush quickly? Emotions Foods Temperature changes Other How many glasses of water do you drink in a day? (240ml) How many glasses of alcohol do you drink in a day? How many caffeinated beverages do you drink in a day? Do you exercise regularly? Yes No Are you ever exposed to chemicals, oils or other caustic substances that may aggravate your skin? Have you ever had a skin treatment in the past? How was your experience? Have you ever had any skin reactions following an aesthetic treatment? Are you using any prescription skin products or products that contain Retin-A, Renova, Adapalene Hydroxyl Acid, Differin, Glycolic Acid, Salicylic Acid, Retinol/Vitamin A, Accutane? Thank you!
