Client Forms – Glowgirl Skincare

In order to properly prepare for your visit, please complete the following forms.

Glowgirl Skincare Consultation Questionaire

Name *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

Birthday Month/ Day

Emergency contact : *

What are your main goals for this visit?

If you could wave a magic wand, how would your skin look in one month?

Please tell me your current skincare regimen- what products you use, how often, etc.

Do you wear makeup? If so, which brands?

Please describe your skin -any history of or present acne, rosacea, melasma, eczema, psoriasis, or other diagnosed skin conditions?

How stressed do you feel on a regular day on a scale from 1-5 (1 = no stress, 5 = extremely stressed)?

How do you manage your stress?

Please describe your sleep - do you sleep well, trouble falling asleep/staying asleep, wake frequent, how many hours of sleep, etc?

How much water have you had today?

How often do you get regular facials?

Please list any supplements or medications you take: *

Birth control history:

Do you have a history of yeast infections or urinary tract infections?

Any known allergies or sensitivities to any food, chemical/ingredient, animal, or substance? *

What role does exercise/fitness/movement/sports play in your life?

Have you ever had any medical aesthetic procedures (microdermabrasion or chemical peels),or any cosmedic procedures (Botox or Fillers), or cosmetic surgery? Please explain. *

Have you ever been prescribed any form of retinoid acid (Retin-A, Accutane,etc), antibiotics, corticosteroid, or hydroquinone for your skin? If so, how long did you take it? *

Any history of cancer or autoimmune or chronic disease? *

Do you experience constipation, diarrhea, , gas or bloating? Please explain.

Any pain, stiffness, or swelling?

Any food cravings?

Please share an example of a typical day of your diet -breakfast, lunch, dinner, snacks, beverages:

Is there anything else you'd like to share (Medical, health issues, emotional, bodily conditions, metal plates, cold sores, herpes etc) ? The more I know, the better your results. *

Knowing that homecare is a big part of achieveing radiant, glowing skin, would you like me to recommend products in order to maintain today's results?

Yes, give me the scoop
No, I'm just here to relax

Learning about my clients helps me provide superior customer service. All information shared is strictly confidential.Is there anything else you want to share?

I give my consent to receive treatment from this practitioner, and have answered all of the questions truthfully. *