Expert Advice – Skin and Wellbeing Consultation Fields marked with * are required Name: * Email: * Phone: * Age: Select 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 Occupation: Within the last year, have you had any health problems that have affected or could affect your skin? Yes No If yes, please specify below: Please list any medications you are currently taking, as these may affect which products are safe to use on your skin: Do you have any allergies? * Yes No If yes, please specify below: Are you pregnant or breastfeeding? * Yes No What are your specific concerns/challenges with your skin? Please list the current skin care products you are currently using on your face and when? Please list for Morning, Evening and Weekly Does your skin ever feel flaky, dry or tight? Flaky Dry Tight How often do you get breakouts? Do you have a tendency to redness? Yes No Do you ever experience burning, itching or stinging sensations on the skin? Burning Itching Stinging Do you wear make-up? Yes No Describe your current routine: Do you have any make-up challenges that you would like help with? Do you exercise regularly? Yes No If yes, does it tend to be indoors or outdoors? Indoors Outdoors Do you sunbathe or use tanning beds? Yes No Do you follow a specific diet? Yes No How much water do you drink per day? How many caffeinated beverages do you drink per day? Rate your level of stress: 1 2 3 4 5 1 = Low stress, 5 = High stress Rate how well you usually sleep: 1 2 3 4 5 1 = Poor, 5 = Excellent Please list the current products you currently use on your body: Do you tend to bath or shower? Bath Shower Is this in the morning or evening? Morning Evening Do you suffer from muscular tension and if so where? Is this tension ongoing or short-term? Ongoing Short-term N/A Does the skin on your body ever feel dry? Yes No Do you exfoliate your body? Yes No Submit
