Name *

First Name

Last Name

Are you prone to any of the following

Please click those that apply to you.

Psoriasis

Eczema

Rosacea

Keloid Scarring

Herpes Simplex

Please indicate are you or do you have any of the following

These conditions are contraindicated to the Environ® DF Ionzyme® electrical treatments. *These require doctors consent Please click those that apply to you.

Pregnant

Pacemaker

Porphyria

Diabetic*

Epilepsy*

Cardiac Irregularities*

Metal Plate/Pins

Radiotherapy*

Chemotherapy*

Moles or Sun Spots Removed*

History Thrombosis/Embolism*

Circulatory Disorders*

Multiple Sclerosis*

Sonophoresis Caution

Please click those that apply to you.

Hearing implants

Tinitus

Have you been treated with any of the following?

Please click those that apply to you.

Hormone Replacement Therapy

Bioidentical Hormone Replacement Therapy

Contraceptive Pill

Topical Corticosteroids

Oral Corticosteroids

Topical Antibiotics

Oral Antibiotics

Topical Vitamin A (Retin A)

Roaccutane

Acne Medication (e.g. Benzoyl Peroxide, Azelaic Acid, Alpha Hydroxy Acids)

Blood Thinning Medication (e.g Warfarin)

Please indicate if you are having or have had any of the following

CST (Immediately after treatment)

IPL (Immediately after treatment)

Laser Treatments (Wait 2 weeks)

Microdermabrasion (Immediately after treatment)

Electrolysis (Wait 2-3 days)

Facial Waxing

Botox (Wait 2 weeks)

Fillers (Consult Practitioner)

NONE

Tell me what are your main concerns?

Lines and wrinkles

Dark spots

Eye area

Dryness/dehydration

Firming/lifting

Redness/sensitivity

Sun damage

Visible pores

Lack of radiance

Scarring/texture

Oil control

Blemish prone

Tell me more about your skin care and make-up routine

Eye Make-Up Remover

Pre-Cleanser

Cleansers & Toners

Exfoliators/Masks

Eyes

Serums

Moisturisers

Sun Protection

Body

Treatments/Facials

Foundation

Eye make-up

Cheeks

Lips

How do your cheeks look and feel?

Dry

Sensitive

Comfortable

Shiny

Oily

How does your T Zone look and feel?

Dry

Sensitive

Comfortable

Shiny

Oily

Describe the environment that your skin lives in

Urban

Frequent travel

Suburban

Office

Outdoor activities

Air conditioning

What kind of sun exposure do you get?

Very Low

Low

Moderate

high

Very High

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

Less than 4 hours

5 hours

6 hours

7 hours

8 hours or more

How would you describe your stress levels?

Very Low

Low

Moderate

High

Very High

Are you any of these?

Vegan

Vegetarian

On a diet

Breast Feeding