Skin Consultation Form

GeeZone
Massage, Health & Beauty Therapies

Client Skin Consultant 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:                                  County:                         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?:  Yes [ ]  No [ ]

Do you consider yourself to have sensitive skin?: Yes [ ] No [ ]

Are you allergic to any specific product or ingredient ?:   Yes [ ] No [ ]
(If yes please specify):

Do you ever experience...
Flaking?   Yes [ ] No [ ]
Tightness?  Yes [ ] No [ ]
Obvious Dryness? Yes [ ] No [ ]

Do you experience breakouts?: Yes [ ] No [ ]

In which area of the face?:

Does your skin...
Flush Easily?          Yes [ ] No [ ]

Feel Hot?               Yes [ ] No [ ]

Feel itchy or sting ?  Yes [ ] 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 [ ] No [ ]
(If yes please specify):

Are you pregnant or intending to become pregnant? :    Yes [ ] No [ ]

Skin Concerns:

Have you ever taken Roaccutane?: Yes [ ] No [ ]
(If yes please specify):

Have you ever taken any other skin medication?:   Yes [ ] No [ ]
(If yes please specify):

Are you currently using any products containing...
Glycolic [ ]
BHA-Salicylic Acid [ ]
Vitamina A [ ]
Vitamin 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 [ ] No [ ]


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