Wellness Questionnaire We can’t wait to have you in the studio! please fill out this questionnaire at least 48 hours before your skin consultation. CONTACT INFO Name * First Name Last Name Email * Phone * CLIENT HEALTH and DIET Age * Please List Any Medications You Are Currently Taking * Please List Any Allergies * Please List Any Vitamins, Herbs, Or Supplements You Take Regularly * Does Your Diet Include Any Of The Following? * Dairy Peanuts Wheat Fruit Soy Sugar No, my diet does not include any of the above. Daily Intake Of Water (Cups) * Daily Intake Of Coffee (Cups) * Daily Intake Of Tea (Cups) * Daily Intake Of Soda (Cans) * How Often Do You Drink Alcohol? * Do You Use Tobacco Products? * Yes No Are You Pregnant, Trying to Become Pregnant, Or Lactating? * Yes No LIFESTYLE What do you do for work? * What do you do for fun? * Describe the environment you live in. * Urban, suburban, rural, mountains, desert, etc. How would you describe your sleep routine? * Great! I fall asleep quickly and feel rested when I get up. I sleep ok. Some nights are better than others. I fall asleep ok but have trouble staying asleep. I have a hard time falling asleep and often wake up tired. I have a very hard time falling asleep and staying asleep. Rate your stress/unrest levels on a day where you go to work or school. * 1 being no stress at all, 10 being harsh stress levels. 1 - not stressed 2 3 4 5 6 7 8 9 10 - very stressed Rate your stress/unrest levels on a day where you're off work or school. * 1 being no stress at all, 10 being harsh stress levels. 1 2 3 4 5 6 7 8 9 10 Have you ever had your hormone levels checked? If yes, was any imbalance detected? If no, write N/A. * Please list your current self-care habits. * REASON FOR CONSULTATION What top concerns lead you to schedule a Wellness Consultation? * Is There Anything Else I Should Know? * Thank you!