Client Consultation Form

Client Consultation Form Date: 1 November 2024 Client Details: Full Name: Sarah Elizabeth Jenkins Date of Birth: 15/03/1992 (Age: 32) Address: 42 Oak Tree Lane, London, SW1A 0AA Phone Number: 07700 900345 Email: sarah.jenkins@example.com Emergency Contact: Name: David Jenkins (Husband) Relationship: Husband Phone Number: 07700 900346 Medical History: General Health: Generally good. No major chronic illnesses. Known Allergies: Penicillin, dust mites. Medications: Oral contraceptive (Yasmin). Past Surgeries/Procedures: Appendectomy (2005). Skin Conditions: History of occasional mild acne breakouts, particularly around menstruation. Sun-sensitive skin. Other Relevant Medical History: None. Current Concerns/Reason for Visit: Client presents with concerns regarding persistent redness and flushing on her cheeks, particularly after sun exposure or consuming spicy foods. She also notes some small, red bumps that appear intermittently. She is seeking advice on managing these symptoms and improving her overall skin appearance. She has tried over-the-counter soothing creams with limited success. Lifestyle Factors: Diet: Balanced diet, occasional spicy food. Exercise: Regular (3-4 times a week). Smoking Status: Never Smoked. Alcohol Consumption: Social drinker (1-2 units per week). Sun Exposure: Moderate, works indoors but enjoys outdoor activities on weekends. Always uses SPF 30+ when outdoors. Stress Levels: Moderate, related to work. Skincare Routine: Cleanser: Gentle foaming cleanser (AM/PM). Moisturiser: Hydrating lotion (AM/PM). SPF: SPF 30 daily. Other Products: Occasional salicylic acid spot treatment. Client Goals: Reduce facial redness and flushing. Minimise appearance of small red bumps. Achieve a more even and calm complexion. Understand triggers and preventative measures. Consultation Notes: Initial Observations: Upon examination, patient presents with diffuse erythema across the cheeks and nose, consistent with rosacea. Telangiectasias are visible on both cheeks. No active pustules or papules observed today, but patient describes their intermittent presence. Skin texture appears slightly bumpy in affected areas. Forehead and chin appear clear. Discussion with Client: Discussed potential diagnosis of rosacea, explaining common triggers and the chronic nature of the condition. Emphasised the importance of sun protection, avoiding harsh skincare products, and identifying personal triggers. Reviewed current skincare routine and suggested alternatives. Patient expressed understanding and willingness to follow recommendations. Recommendations/Treatment Plan: 1. Topical Metronidazole gel 0.75% applied thinly to affected areas twice daily. 2. Recommend a gentle, fragrance-free cleanser and moisturiser suitable for sensitive skin (e.g., Cetaphil, La Roche-Posay). 3. Strict sun protection: daily use of broad-spectrum SPF 50+, wearing a wide-brimmed hat when outdoors. 4. Avoid known triggers: spicy foods, hot beverages, alcohol, extreme temperatures. 5. Consider oral doxycycline 20mg once daily if topical treatment alone is insufficient after 4-6 weeks. 6. Follow-up appointment in 6 weeks to assess progress and adjust treatment plan if necessary. Future Appointments: Date: 13 December 2024 Purpose: Follow-up on rosacea treatment. Consultant Dermatologist: "Dr. Eleanor Vance" Signature: E. Vance Date: 1 November 2024