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 Home >> Enquiry Form
Name :
Address :
Tel :
Mobile :
E-mail Address :
The following profile should be completed for all customers enquiring about our Healthcare and Skincare products.
This is to correctly evaluate your needs in healthcare, skin care products used at home or away.
This information is completely confidential and to be used only for this analysis.
Client History    
Please answer as much questions as you can. Thank You.
1. What skin type are you? :
2. What is your age? :
3. Do you have any allergies? Please tick :
Yes No
4. Are you currently, or within the last year, under a physicians care? Please tick :
Yes No
5. Have you undergone any surgery in the last nine months? Please tick :
Yes No
If Yes, please specify :
6. Have you had any of these health problems in the past or present?  Please Tick
Cancer Hormone imbalance Diabetes
Hysterectomy Epilepsy Thyroid
Heart problem Varicose veins  
7. List any medications and vitamins that you take regularly.
Medications :
Vitamins :
8. Do you smoke?   :
Yes No
Had chemical peels? :
Yes No
Use Retin-A? :
Yes No
Ever used the acne drug, Accutane? :
Yes No
Follow a restricted diet? :
Yes No
Exercise regularly? :
Yes No
Have regular sleep patterns? :
Yes No
Have you hair frosted, highlighted or chemically – lightened? :
Yes No
Wear contact lenses? :
Yes No
Have metal implants or pace maker? :
Yes No
9. What temperature of water do you use to cleanse with?  
10. Do you have any special skin problems pertaining to your face? :
Yes No
If Yes, please specify :
11. Do you have any special concerns pertaining to your body? :
Yes No
If Yes, please specify :
12. What types of skin care products are you currently using? Please tick
Soap Toner Masque
Cleanser Moisturizer Scrub / Peel
Other    
13. Have you ever had a body spa treatment before? :
Yes No
If Yes, Which treatments? :
For Female Clients Only
14. Are you taking oral contraception? :
Yes No
15. Are you pregnant or trying to become pregnant? :
Yes No
Male Clients Only
16. What is your current shaving system? :
17. Do you ever experience irritation from shaving? :
Yes No
18. Do you experience ingrown hair? :
Yes No
Oil Secretion
1. Do you experience breakthrough oily shine during the day? :
Yes No
2. Do you experience skin breakouts? :
Yes No
Moisture hydration
1. How much plain water do you consume daily? :
2. Do you take laxatives or diuretics? :
Yes No Ocasionally
3. How many alcoholic beverages do you consume weekly? :
1-3 4+
4. Do you ever experience these conditions on your skin? Please tick
Flakiness Tightness Obvious Dryness
5. If you sunbathe, do you use a sunscreen / sunblock on your skin? :
Yes No
Capillary activity
1. Do you burn easily in moderate sunlight? :
Yes No
2. Do you blush easily when nervous? :
Yes No
3. Do you have a tendency to redness? :
Yes No
4. Have you ever suffered any sinus problems? :
Yes No
Nerve Activity
1. Do you drink caffeinated beverages (coffee, tea, soft drinks)? :
Yes No
How many daily?
 :
2. Do you take any stimulants or slimming tablets? :
Yes No Ocasionally
3. What level do you consider your pain threshold to be? :
Low Medium High
4. Have you ever experienced any claustrophobia? :
Yes No
5. What type of massage pressure do you prefer? :
Light Firm
6. Have you ever had a reaction to any of the following? Please tick
Cosmetics Pollen Animals
Medicine Food Fragrance
Iodine AHAs Sunscreens
Others    
Please fill in any questions and the name of the healthcare / skincare products you are enquiring about and any other information you would like us to know.
 
         
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