Ninian Smith, Consultant Trichologists, Hair & Skin Centre
About Us Hair Loss Skin Problems Products Contact Us

SKIN ANALYSIS FORM

Professional Analysis and Treatments for Hair Loss, Scalp Disorders and Skin problems.

Please printout & email, fax or post this form to us.

Instructions

Dermocosmetic Analysis Form

Client Information

Male / Female

Name

Date of Birth

Address………………………………………………………………………………………… ………………………………………………………………………………………… …………………………………………………………………………………………

Post Code………………….. Telephone incl. Area code …………………………….

Ethnic Group Asian………………Afro-Caribbean……………. Caucasian………….Oriental…………….. Other……………………………………..

Occupation ………………………………………………………………………..

Outdoor Activities ………………………………………………………………………..

Swimming ……………………………………………………………………….

Sports ( what and how often ) …………………………………………………………………. ………………………………………………………………………..

Sun Bathing / Sunbed ………………………………………………………………………..

Special Diet ………………………………………………………………………..

Daily Liquid Intake ………………………………………………………………………..

General Health ………………………………………………………………………..

Stress Level ………………………………………………………………………..

Illness in the last 12 months……………………………………………………………………..

Recent surgical intervention…………………………………………………………………….

Prescribed Medicines ……………………………………………………………………….. ………………………………………………………………………..

Family Skin History ……………………………………………………………………..…

( Genetic History ) Fathers side………………..Mothers side……………….

Additional Information & Comments ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… ………………………………………………………………………………………………

Present Skin Care Products normally used…………………………………………………………………….. …………………………………………………………………….. ………………………………………………………………………

Cleansing ………………………………………………………………………

Day Cream ……………………………………………………………………….

Night Cream ……………………………………………………………………….

Other ………………………………………………………………………. ……………………………………………………………………….

Visual Observations Skin Condition

Flakiness……….Redness…………..Irritation………….. Dilated Pores……….. Blackheads…………. Complexion Dull………… Pink………… Pale……….. Wrinkles Crows Feet ………….

Around the mouth ………… Neck ………… Face …………

Acne Yes ………… No………. ( If yes , please give further information in Info. Section ) i.e. Is acne pustular, weeping, blackheads, what areas are affected, chin, forehead, around cheeks, what treatments have you been using and for how long etc. Please give as much information as possible.

Manual Observations Elasticity - Face Good…………Average……….Poor………..

Neck Good…………Average……….Poor………..

Pinch and lift the skin between the forefinger and thumb, See how long the skin takes to return to normal

Skin Thickness Thick………Normal………Thin……..

Lift the skin and feel the thickness with the fingers. Supplementary Information Body Skin condition Dry………… Rough………… Atonic……….

Cellulite None……… Moderate……… Severe……….

Water Retention Yes………… Only Periodically………….

Make up Stable ? Yes…………. No………….

The Sun Reactions to sunbathing Yes…………. No…………. Tan Easily Yes………… No…………..

Please answer as many questions as possible, leave blank any you cannot answer.

All skin preparations are prescribed on an individual basis Please incl. £12.50 Sterling Fee. When Skin analysis complete, a full report and rec. on treatments and prices will be sent. Please pay analysis fee of £12.50 and send to the address below. Alternatively, the analysis form can be e-mailed and fee paid by credit card. If you require any further information about this process please e-mail or telephone us at 01475 724629. A full analytical report will be e-mailed or sent to you detailing recommended treatments.

Should you decide to proceed with the treatments you may order via e-mail or by post, including your cheque.