Consultation Form

Select your current level of stress *

	1	2	3	4	5	6	7	8	9	10

1 is Low, 10 is High

Select your normal level of stress *

	1	2	3	4	5	6	7	8	9	10

1 is Low, 10 is High

How many Litres of water do you drink per day *
Do you take supplements / Vitamins *

Yes No
Do you Exercise *

Yes No
If you Exercise, explain how often
When were you last Sunburnt (If never say so) *
Do you use Tanning Beds *

Yes No
When you go out in the sun do you (Check One only) *

Always Burn Usually Burn Sometimes Burn Rarely Burn Very Rarely Burn Never Burn
Have you ever been under the treatment plan of A

Dermatologist Plastic Surgeon Esthetician
If you have checked the previous question what Procedure or Treatment
Are you concerned about skin conditions on your body (Check all that apply)

Sun Spots Skin Laxity Dry / Rough
What skin products are you currently using (If None say so) *

How do you feel About the overall quality of your skin *

	1	2	3	4	5	6	7	8	9	10

1 is It could be better, 10 is Looks Great

Your skin type is (Check one only) *

Normal Dry / Dehydrated Oily Acne / Acne Prone Rosacea
In order of importance please rank the following 5 questions for improvement in the next 30 days.
Reduction of fine lines *

1 Star to 5 Stars (1 on the left, 5 on the right)
Acne scars diminished *

1 Star to 5 Stars (1 on the left, 5 on the right)
Reduction of oil / acne *

1 Star to 5 Stars (1 on the left, 5 on the right)
Reduction of brown spots / sun damage *

1 Star to 5 Stars (1 on the left, 5 on the right)
Reduction of redness *

1 Star to 5 Stars (1 on the left, 5 on the right)
Should be Empty:

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