Name
*
First Name
Last Name
Email
*
Are you pregnant or breastfeeding?
Do you have a regular menstrual cycle?
Please list any medication you are currently taking and what you are taking it for.
Please list any medication you have taken in the last 12 months.
Have you had any surgical procedures within the last 12 months? If yes, please stipulate.
Please list any current and previous medical conditions.
Please list all natural therapies/supplementation that you are taking or previously have taken.
Are you taking any blood thinning or anti-inflammatory medication (including Nurofen)?
Have you recently taken antibiotics?
Do you drink alcohol? If yes, how many drinks would you consume in a week?
Do you smoke? If yes, how many a day?
Do you drink tea/coffee? If yes, how many a day?
How many glasses of water do you drink a day?
Do you suffer from any digestive issues including bloating, discomfort or irregular bowel movements?
Please rate your stress levels from 1 – 10 (1 being not very stressed, 10 being very stressed)
What is it about your skin that you would like to improve?
How long has this been bothering you?
What does your current skin care routine consist of? Please select from the following:
You can select multiple options.
Have these products achieved a result for you?
Do you use any products containing these active ingredients?
Do you wear SPF daily?
Please list previous professional skin treatments you have had to address your skin concerns.
Have you ever had chemical peels, IPL, laser or skin resurfacing treatments?
If so, please specify and when?
If you have ever had an allergic reaction to a skincare product, treatment or ingredient, please describe the reaction and product/treatment:
How would you categorise your skin?
