Skin Consultation Form

Massage, Health & Beauty Therapies

Client Skin Consultation Card

For a customised programme specifically designed for your skin, please complete the form below and our fully qualified Beauty Therapist will recommend the right products for you!

Client Name:            Client Address:
City:                          Post Code:
Email Address:Home Phone:  Mobile Phone:Work Phone:D.O.B:   /

How did you hear about us?:

Preferred Therapist:
_______________________________

SKIN HISTORY

Do you have skin allergies?: [ ]  No [ ]
Do you consider yourself to have sensitive skin?: Yes
Are you allergic to any specific product or ingredient ?: Yes(If yes please specify):
Do you ever experience...Flaking? NoTightness? [ ] NoObvious Dryness? Yes

Do you experience breakouts?: Yes [ ]

In which area of the face?:
Does your skin...Flush Easily?         Yes [ ]

Feel Hot?      Yes [ ]

Feel itchy or sting ? [ ] No [ ]

What concerns you about your skin?:

VARIOUS MEDICATIONS MAY AFFECT THE SKIN:

Health Concerns:

Concern:
Medication:
_____________________________________________
Concern:
Medication:
_____________________________________________
Concern:
Medication:

Are you taking any vitamins? : Yes [ ]


Are you pregnant or intending to become pregnant? : Yes

Skin Concerns:

Have you ever taken Roaccutane?: Yes(If yes please specify):
Have you ever taken any other skin medication?: [ ] No(If yes please specify):
Are you currently using any products containing...
GlycolicBHA-Salicylic AcidVitamina AVitamin C [ ]
Vitamin E [ ]
Pentapeptides [ ]
Essential Oils [ ]
Ceramides [ ]

Have you had any of the following procedures ...
Plastic Surgery [Chemical Peel ]
IPL [Laser ]
Microdermabrasion [
Skin Cancer Removal [

DIET & LIFESTYLE:

Is your diet balanced or unbalanced...

Low Fat [High Fat [
Alcohol Consumption [High Sugar [
How much plain water do you consume daily...
1 Glass [2 Glasses [3 Glasses [1 Litre [ ]
2 Litres or more [ ]

Do you have a problem with constipation?
Yes [ ] No [ ]

Do you smoke?
Yes [ ] No [ ]

Do you exercise regularly?
Yes [ ] No [ ]

Are you taking oral contraception?
Yes [ ] No [ ]

What would your stress level be?
Low [ ]
1 2 3 4 5 6 7 8 9 10 =
High [ ]

What results/improvements are you looking for?
Low [ ]
1 2 3 4 5 6 7 8 9 10 =
High [ ]

SKIN CARE:
Which brands of skin care are you currently using?

PLEASE TICK PRODUCTS PRESENTLY BEING USED AND STATE FOR WHAT SKIN TYPE THEY ARE FOR:

Cleanser:

Toner / Lotion:

Exfoliant:

Eye Cream:

Day Cream:

Night Cream:

Serum / Ampoules:

Mask:

Sun Block:

Make up Foundation:

Specialty Product:

Body Products:

DO YOU CONSENT TO RECEIVING E-MAIL,
NEWSLETTERS & COMMUNICATIONS FROM US?
Yes ] [

Copy, paste & email completed form to geeoz5@aol.com.

Tel/Mob: +44(0)7931 100 093 / 07817 967 102
Email: geeoz5@aol.com
Website: www.geezone.biz