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Name
First Name
Last Name
DOB
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MM/DD/YY
MM
DD
YYYY
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Please list all current products used in your AM+PM REGIMEN , Be as specific as possible, this allows me to gage the health of your skin barrier
(include any item that touches your skin like exfoliants and makeup)
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Skin concerns
skin health maintenence
Sluggishness
Congestion (clogged pores, comedones)
Inflammation (deep, pustular or nodular lesions)
hyperpigmentation (PIH- RED)
Hyperpigmentation (brown)
dryness (lack of lipids)
dehydation (lack of water)
barrier disfunction (redness, stinging, burning)
slow wound healing
wise skin (lines, wrinkles, loss of elasticity)
rosacea
eczema
peri oral dermatitis
skin allergies and rashes
puffiness
happy, balanced, well functioning skin
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Skin Nutrition
vegan
vegetarian
conventional meat or poultry
organic, local, grassfed, or pasture-raised animal products
leafy greens, and fiber-rich veggies
whole grains like brown rice, millet, quinoa
refined carbs and grains (white flour, white rice, etc)
sweets, candy, baked goods
fruits: conventional or organic
healthy fats : avocado, olive oil, walnuts, almonds, olives
refined oils : canola, cottonseed, margerine
herbal teas
coffee or other caffeine products
Dairy products: cheese, yogurt, milk, cream
Soy products: tofu, soy milk, soy sauce
Soft drinks, sweetened beverages
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Digestion + Assimilation
daily bowel movements (long + formed)
daily bowel movements (loose)
daily bowel movements (hard + dry)
not eliminating daily
Checkbox
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Contraindications
Pregnant
Pace maker
Herpes Simplex (oral)
Recent injections (Botox, Filler)
Easy bruising/wounding
Low blood pressure
Local infection (ringworm, boils, impetigo)
Fever
Cancer
Diebetes
Auto-immune Conditions
none
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Sleep (nature's cure-all)
sleeping 8-9 hrs nightly
sporratic sleep schedule
issues falling asleep
issues staying sleep
wake up feeling rested
wake up feeling fatigued
sleeping less than 7 hrs nightly
Previous skin treatments
topical antibiotics
topical retinoids
accutane
chemical peels
topical steroids
laser treatments
microdermabrasian treatments
dermaplaning treatments
over the counter acne treatments
proactive
hormonal birth control
Other factors that can influence your skin ecosystem
Gut imbalances
irregular cycles for folks who bleed
low stomach acid / reflux
food allergies
food sensitivities
hyper/hypothyroid
high cortisol
compromised immune system
Any other things you'd like to share with me before I touch your skin?
Date
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MM
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