Online Consultation Form

Your online skin consultation form is the first step in understanding your skin and creating a personalised skincare plan. It has been designed to gather important information about your skin history, concerns, lifestyle and overall skin health.

Please complete each section as thoroughly and accurately as possible. The more information you provide, the better I can assess your skin and offer appropriate advice.

All information you submit is treated as strictly confidential and is securely stored in accordance with the UK General Data Protection Regulation (UK GDPR).

Full Name

First NameLast Name

Date of Birth

Date

Address

Street Address

Street Address Line 2

TownCounty

Post Code

Email Address:

Example: bev@thebeautybistro.co.uk

Telephone Number:

Please indicate if any of the following apply:

Have you been diagnosed with any form of cancer within the past five years? If yes, please provide details including the type of cancer, date of diagnosis and any treatment received.

Have you been diagnosed with diabetes? If yes, please provide details (Type 1, Type 2, or other, and whether it is controlled with medication or insulin).

Do you have any diagnosed digestive or bowel conditions (for example IBS, coeliac disease, crohn’s disease, ulcerative colitis etc)? If yes, please provide details.

Do you have any known food intolerances or notice that certain foods affect your skin or wellbeing? If yes, please describe the foods and the reaction you experience.

Do you have any other medical conditions that have not beeen listed above? if yes, please advise.

Are you under the care of a medical professional or specialist?

Have you taken any antibiotics in the last 6 months?

Have you taken Roaccutane within the last 12 months?

Are you currently taking hormone replacement therapy? (HRT)

Have you ever been diagnosed with PCOS (Polycystic Ovary Syndrome)?

Do you notice changes in your skin related to your menstrual cycle? If yes, please explain further.

Do you have any known allergies (for example skincare ingredients, medications, latex, food or environmental allergens)? If yes, please provide details.

Are you currently taking any prescribed medications, including oral or topical (creams)? If yes, please list the medication and what it is prescribed for.

Please mention contraceptives and HRT here, if relevant

What are your main skin concerns? Please describe in as much detail as possible. Where relevant, include: When the concerns first developed. How they have changed or progressed over time . Any triggers or factors that appear to worsen them. Any treatments or skincare you have previously used for these concerns

What would you like to achieve or learn from your skin consultation?

How would you describe your skin? (For example dry, oily, combination, sensitive, reactive) What changes occur during the day?

Example: My skin feels tight after washing, in the afternoon it looks greasy in the middle of my face.

How would you describe your skin tone? (For example fair, light, medium, olive, brown or dark.)

Please state your nationality.

Have you ever experienced a reaction to any skincare ingredients, products or brands? If yes, please list the product and describe the reaction experienced.

Does your skin easily become sensitive, red, irritated, sore, hot or bruised? If yes, please provide more details

Which skincare brands are you currently using? Please list all brands used in your skincare routine.

Please list the FULL NAME and brand of each skincare product you are currently using.

Example: Environ Hydra intense cleanser, Environ AVST 2 Moisturiser etc

Please explain how you apply your skincare products, in the order that you apply and the quantity. Please fully complete both morning and evening routines.

Morning: Cleanse with 2 pumps of Environ Hydra Intense cleanser, massage in for 30 seconds, rinse with warm water and dry. Apply one pump of Environ AVST 2 Moisturiser and massage in until absorbed. Etc

How does your skin usually feel after cleansing?

Why did you choose the skincare products you are currently using? (For example recommendation from a professional, friend suggestion, social media, influencer advice, or personal research.)

Have you ever experienced redness, peeling, tightness or irritation after using skincare products? If yes, please provide details.

How often do you exfoliate your face, and what type of exfoliation do you use (for example scrubs, acids or enzyme products)?

Do you regularly have facials or professional skin treatments? If yes, please indicate how often and the type of treatments received.

Do you perform any skin treatments at home? If yes, please advise what you do and how often.

Example: peels, microneedling, face masks, dermaplaning, skin cleansing devices., radiofrequency, muscle stimulation etc

How often do you apply SPF (sun protection)? Please indicate if this is daily, occasionally or only in sunny weather, and if/when you reapply.

Example of content required: I apply a pea-sized amount of SPF to my face and neck after my morning skincare routine. I reapply my SPF every 90 minutes when in the sun. In winter, I only apply SPF once a day in the morning after my skincare routine.

Do you use sunbeds or spend time intentionally sunbathing? If yes, please indicate how often.

How does your skin typically respond to sun exposure?

What is your occupation? Please include any workplace factors that may affect your skin (for example outdoor work, heat, shift work, most of the day spent at a computer, air conditioning or exposure to chemicals).

Do you suffer with stress?

Do you feel that, stress, anxiety or emotional wellbeing affects your skin? if yes, please describe.

If you regularly exercise or take part in activities that cause perspiration (for example gym workouts, running, cycling or hot yoga etc)? How soon after do you cleanse your skin?

Do you regularly wear helmets, hats, headbands, or tight sports clothing during exercise? If yes, please explain.

On average, how many hours of sleep do you get per night?

Do you follow any specific dietary pattern (for example vegan, vegetarian or other)? If yes, please provide details.

Do you suffer with brittle nails or hair?

Are you currently taking any dietary or nutritional supplements? If yes, please list the brands and daily quantities

Please list the brand and the product name

Do you consume alcohol?

How much water do you drink on average each day?

Do you currently smoke or vape? If yes, please provide details.

How often do you smoke or vape

How often do you consume foods high in sugar or dairy products in a week? Please provide details.

Milk, cheese, ice-cream, chocolate, yoghurt, butter, cream, biscuits, cakes etc

How many eggs do you consume in a week, on average?

Is there any additional information you feel may be relevant to your consultation? Or do you have any questions you would like to ask me?

Please provide images of your skin. Images must be taken in good light with clean skin and no makeup or skincare products applied.

The Beauty Bistro Ltd cannot accept responsibility or liability for any adverse reaction resulting from advice or skincare products recommended where relevant medical conditions, allergies, medications, or other health information have not been fully disclosed. By submitting this consultation form, you confirm that you have read and answered all questions truthfully and to the best of your knowledge.

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Online Skin Consultation

£50.00

Total

Payment Methods

Credit Card

Google Pay

Clearpay

Do you have any questions you would like to ask? Or do you have any other information that may be relevant to your skin that may not have been mentioned in the form?

How many sugar and dairy products do you consume on a daily basis?

Example of required content; Full fat milk 3 x glasses daily. 2 x eggs a day and 1 yoghurt. I enjoy a chocolate bar in the evenings.

Have you used any Vitamin A in the last 5 days.

Have you used any Vitamin A, or Retinoid products in the last five days?

Please state which products

Do you have any problems/irregularities with your monthly menstrual cycle?

Example of required content: My cycle has been irregular since around 20 years of age and I experience painful stomach aches with heavy bleeding for around 5 days. I am going to try the Mirena coil to alleviate my symptoms as advised by my Dr.

Do you have any food intolerances that you know of or do you react to certain foods?

Example - Medically diagnosed with an Intolerance to milk and eggs around 4 years ago. If I consume these I suffer with extreme bloating and upset stomach. I also don't eat tomatoes as they bring me out in a rash.

Do you suffer from any bowel or digestive conditions such as constipation, diarrhoea, IBS, Crohn's disease, Coeliac disease, etc or bloating?

Please advise how long you have had your condition.

Do you experience hormone imbalances?

Example of required content: I haven't been medically diagnosed, although every month I have a breakout around my chin.

Are you taking any food supplements if so, please list the brands and quantity taken daily?

Example of required content: Omega 3 & 6 from the Advanced Nutrition Programme x 4 capsules taken daily with food. I x Probiotic taken daily from the same brand.

Are you on HRT? Please provide the brand of HRT and the length of time you have been on it.

Example: Evorel 100 patches and have been using them for 5 years.

Do you smoke or vape?

Example of required content: I vape throughout the day but more at night watching the TV.

What is your nationality and skin colour?

Do you drink alcohol ?

How many units a week?

Are you diabetic?

Do you suffer with brittle nails and hair?

How many hours do you sleep on average a night?

Do you have an over active or under active Thyroid?

Please explain

How many glasses of water/fluids do you drink daily?

Ex; 8 x glasses of water a day

Online Skin Consultation Form

Medical History and Allergy Information

SKIN CONDITION, SKIN BACKGROUND & SKIN ROUTINE

Lifestyle and Diet

Additional Information

My Products

Payment Methods