Client Consultation Form  
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Full Name *
Date of Birth *
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Phone Number *
Address *
Email *
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In case of emergency: *
Your Skin Goals and Concerns: *
What skincare and makeup products are you currently using? *
Does your job and lifestyle require that you work/play outdoors? *
Do you wax your face on a regular basis? *
If yes when was the last time you waxed?
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:
Are you using? Retin-A *
Are you using? Benzoyl Peroxide? *
Tell me about any allergies or sensitiveness you have: *
Have you ever experienced a reaction to any of the following? *
Required
When was your most recent dental work and what procedure: *
Do you use Botox/Fillers, if so when was your last treatment: *
Tell me about any health issues you have: *
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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DD
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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
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
Clear selection
Metal Element: Lungs/ Large Intesine                      
Rarely or never experienced
Occasionally experienced, effect not severe
Occasionally experienced, effect is severe
Frequently experienced, effect not severe
Frequently experienced, effect is severe
Frequent illness
Hives, rashes, dry skin
Excessive sweating
Stuffy Nose
Sinus problems
Hay Fever
Sneezing attacks
Excessive mucus
Underweight
Sadness
Chronic coughing
Chest Congestion
Asthma/ bronchitis
Shortness of breath
Difficulty Breathing
Clear selection
Wood Element: Lungs/ Large Intesine                      
Rarely or never experienced
Occasionally experienced, effect not severe
Occasionally experienced, effect is severe
Frequently experienced, effect not severe
Frequently experienced, effect is severe
Anger/ easily frustrated
Waking up between 1 - 3am
Insomnia
Depression
Poor physical coordination
Accident prone
Headaches/ migraines
Vertigo
Cramps
Irregular periods
Heartburn
Nausea/ vomiting
Eye tension
itchy watery eyes
Dry eyes
Blurred/ tunnel vision
Poor night vision
Addictive tendencies
Acne
Clear selection
Water Element: Kidneys/ Bladder                    
Rarely or never experienced
Occasionally experienced, effect not severe
Occasionally experienced, effect is severe
Frequently experienced, effect not severe
Frequently experienced, effect is severe
Brain fog
Fatigue
Anxiety / Fear
Poor Memory
Tinnitus/ Ear Ringing
Itchy Ears / Drainage
Earaches/ Infections
Poor concentration
Sluggishness
Depression
water retention
stiffness in joints
Arthritis
Dark circles/ Bags
Low libido
Hair loss
Frequent / urgent urination
Clear selection
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