What skincare and makeup products are you currently using? *
Your answer
Does your job and lifestyle require that you work/play outdoors? *
Your answer
Do you wax your face on a regular basis? *
If yes when was the last time you waxed?
Your answer
Have you ever had facials, chemical peels, microdermabrasion, or any resurfacing treatments? *
If yes, was it within the last month? *
If yes what procedure did you have:
Your answer
Are you using? Retin-A *
Are you using? Benzoyl Peroxide? *
Tell me about any allergies or sensitiveness you have: *
Your answer
Have you ever experienced a reaction to any of the following? *
Required
When was your most recent dental work and what procedure: *
Your answer
Do you use Botox/Fillers, if so when was your last treatment: *
Your answer
Tell me about any health issues you have: *
Your answer
Please tick if any of the following apply *
Required
Tell me about any medications you take: *
Required
I have read and completed this questionnaire truthfully. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive are voluntary and I release the company and/or skin care professional from liability. *
Required
Date *
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Fire Element: Heart/ Small Intestine
Rarely or never experienced
Occasionally experienced, effect not severe
Occasionally experienced, effect is severe
Frequently experienced, effect not severe
Frequently experienced, effect is severe
Chest pain
Irregular heart beat
Rapid/ pounding heart beat
Difficulty in making decisions
Stuttering/ stammering
Slurred speech
learning disabilities
Hyperactivity
Restlessness
Swollen/ discoloured tongue
Canker sores
Rarely or never experienced
Occasionally experienced, effect not severe
Occasionally experienced, effect is severe
Frequently experienced, effect not severe
Frequently experienced, effect is severe
Chest pain
Irregular heart beat
Rapid/ pounding heart beat
Difficulty in making decisions
Stuttering/ stammering
Slurred speech
learning disabilities
Hyperactivity
Restlessness
Swollen/ discoloured tongue
Canker sores
Clear selection
Earth Element: Spleen/ Stomach
Rarely or never experienced
Occasionally experienced, effect not severe
Occasionally experienced, effect is severe
Frequently experienced, effect not severe
Frequently experienced, effect is severe
Diarrhoea
Constipation
Bloated
Passing gas
Stomach pain
Difficulty making decisions
Feeling of weakness
pain or aches in muscles
Mood swings
Excessive phlegm
Bing eating/ cravings
Excessive weight/ tendency to carry weight in abdomen
Rarely or never experienced
Occasionally experienced, effect not severe
Occasionally experienced, effect is severe
Frequently experienced, effect not severe
Frequently experienced, effect is severe
Diarrhoea
Constipation
Bloated
Passing gas
Stomach pain
Difficulty making decisions
Feeling of weakness
pain or aches in muscles
Mood swings
Excessive phlegm
Bing eating/ cravings
Excessive weight/ tendency to carry weight in abdomen