Aesthetic Consultation & Skin Assessment

This consultation gathers your skincare history, medical background, lifestyle, and aesthetic goals so the provider can offer realistic recommendations tailored to your skin. All recommendations are clinical opinions; no treatment is performed today.

Patient Information

Full name:

Date of birth:

Gender:

Female

Male

Non-binary / other

Prefer not to say

Occupation:

Contact phone / email:

Emergency contact (name / relationship / phone):

Skincare History

Current skincare routine — describe morning and evening:

Products currently used — select all that apply:

Cleanser

Toner

Serum

Moisturizer

SPF / sunscreen

Retinoid (retinol / tretinoin)

Vitamin C

Acids (AHA / BHA / glycolic / salicylic)

Salon / spa facials — frequency:

Never

Occasionally (1–2× per year)

Quarterly

Monthly

Weekly or more

Previous in-clinic treatments — specify type and date:

Lifestyle

Sun exposure:

Minimal — mostly indoors

Moderate

Heavy — frequent outdoor recreation

Occupational outdoor exposure

SPF use:

Daily

Sometimes

Rarely

Never

Smoking:

Never smoker

Former smoker

Current smoker

Vape / e-cigarette user

Alcohol:

None

Occasional / social

Regular (1–3 drinks per week)

Frequent (4+ drinks per week)

Average sleep (hours per night):

Stress level (0–10):

Diet notes — typical eating habits, hydration, supplements:

Medical History

Current medical conditions — please list any:

Chronic skin conditions — select all that apply:

Rosacea

Acne

Eczema / atopic dermatitis

Psoriasis

Vitiligo

Melasma

Keloid scarring tendency

Cold sores / herpes simplex

Currently pregnant or breastfeeding

Recent isotretinoin use (last 12 months)

If yes, date of last isotretinoin dose:

Taking immunosuppressants

Taking anticoagulants / blood thinners

If yes, name of anticoagulant and reason for use:

Other current medications — including OTC and supplements:

Allergies — drugs, latex, lidocaine, hyaluronic acid, topicals, metals, iodine, foods:

Cosmetic Procedure History

Past botulinum toxin / dermal fillers / laser / surgery — date, area, brand, results, complications:

Fitzpatrick Skin Type

Type I — pale, always burns, never tans

Type II — fair, usually burns, tans minimally

Type III — medium, sometimes burns, tans gradually

Type IV — olive, rarely burns, tans easily

Type V — brown, very rarely burns, tans deeply

Type VI — deeply pigmented, never burns

Skin Analysis

Texture: [Provider documents skin texture observed during in-clinic assessment]

Pigmentation: [Provider documents pigmentation findings (even tone / sun spots / melasma / PIH / freckles)]

Lines & wrinkles: [Provider catalogues named line locations observed (forehead / glabellar / crow's feet / nasolabial / marionette / smoker's)]

Vasculature: [Provider documents vascular findings (telangiectasia / rosacea flushing / spider veins)]

Acne: [Provider grades acne sub-classification (comedonal / inflammatory / cystic / acne scarring)]

Pores: [Provider grades pore size (minimal / moderate / enlarged)]

Elasticity / laxity: [Provider grades skin laxity via palpation/inspection (firm / mild / moderate / advanced)]

Hydration: [Provider documents hydration assessment (well-hydrated / dehydrated)]

Areas of Concern

What bothers you most about your skin? In your own words:

Priority ranking — list your top 3 concerns from most to least important:

Patient Goals & Expectations

What does success look like to you?

Readiness for downtime — how much downtime can you tolerate?

None acceptable

1–3 days

1 week

2 weeks

Budget bracket:

Photo Documentation Consent

I agree to clinical photography for my medical record

I agree to before-and-after photos for my own personal review

I agree to portfolio use with my face anonymized

Signed photo consent on file

Recommended Treatment Pathway

Provider's clinical opinion (recommendations are clinical opinions, not guarantees of outcome):

Recommended treatments — up to 4 entries:

Treatment 1 — name: / indication: / estimated cost:

Treatment 2 — name: / indication: / estimated cost:

Treatment 3 — name: / indication: / estimated cost:

Treatment 4 — name: / indication: / estimated cost:

Acknowledgement

The information I have provided is accurate to the best of my knowledge

I understand recommendations are clinical opinions, not guaranteed outcomes

I agree to attend a follow-up consultation if I decide to finalize a treatment plan later

Thank you for completing this consultation. Your provider will review the assessment and discuss the next steps with you before any treatment is scheduled.