Patient Questionnaire Step 1 of 4 - Patient Details0%Personal DetailsName First Last Date of birth DD slash MM slash YYYY Phone*Email* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country What is the main reason for your consultation today?Tell us any of your concerns...Which of these statements are most applicable to you? I would like to have clearer skin I would like to change something that has been bothering me for a long time I would like to look more attractive I would like my skin not to be so painfulHave you had a skin consultation or treatment before? Yes NoHow often do you think about your skin? Most days Weekly MonthlyWhen I think about my appearance, I feel that I look:Please select three. Dull Tired Sad Fresh Happy Bright UnattractiveOn a scale of 1 – 10, 1 being desperately unhappy, and 10 being extremely happy, how satisfied are you with your overall appearance? 1 2 3 4 5 6 7 8 9 10On a scale of 1 – 10, 1 being desperately unhappy, and 10 being extremely happy, how satisfied are you with your skin? 1 2 3 4 5 6 7 8 9 10After the treatment, I would like to feel:Please select three. Fresher Happier Brighter Clearer Skin More attractive More luminous More confidentFrom your selections, list your three desired outcomes in order of priority:1.2.3.Please tick the area(s) that you are concerned about? Face Front Torso Back Torso Arms Legs Feet OtherUpload Photos*Please upload 3 photos of the area(s) you would like us to improve as this will allow our team further insights into how we can assist Drop files here or Select filesMax. file size: 256 MB, Max. files: 3. Which of these statements interest you?SKIN IMPROVEMENT Skincare at HOME More Educated on Myskincare Treatments available to me in the clinicHow did you hear about us? My doctor Ebano Ballinteer Client Recommendation Internet Social mediaConsent* I hereby consent to providing the above data for use in respect of my treatment. In the unlikely event that I experience any adverse reaction, I further consent for this information to be shared with Myskincare, for further investigation and advice.*Practitioner name:Consultation Fee Price: Credit CardCard Details Cardholder Name
