Free holistic Skin Care Consultation - ViVire Wellness and Nutrition

Name *

First

Last

Tell us more about what's going on. Circle any of the symptoms you experience regularly:

Email *

Telephone

Date of Birth ( DD-MM-YY)

Step 1 : Skin Profile

What are your current skin concerns?

How can a moisturizer best benefit your skin?

Checkboxes

First Choice
Second Choice
Third Choice

Which products do you currently use?

Do you exfoliate using any of the following treatments? Check all that apply

Which traits best describe your skin? Check any of the symptoms you experience regularly:

Adaptive Skin

Resilient skin with occasional congestion or breakouts
Oiliness and / or dryness in the T-zone
Periods of dull skin or sun damage
Pore size in average

Stress Reactive Skin

Skin break out during times of stress
Blemishes are small, around mouth and chin
Episodes of red, rashy or dry skin
Family history or psoriasis, eczema or allergies

Hormone Reactive Skin

Skin breaks out before period
Skin is more prone to oil and enlarged blemishes
Post-menopause, skin is drier, more sensitive
After age 40, skin has cysts-like blemishes

Mature Skin

Skin shows wrinkles or dark spots
Skin feels thinner and drier
Skin is less firm
Broken capillaries on nose and cheeks

Step 2: Stress and Your Skin

Tell us more about what's going on. Circle any of the symptoms you experience regularly:

Please indicate any allergies you may have

What is your daily diet

Daily glasses of water

Daily cups of coffee

Daily alcoholic beverages

How many hours do you sleep per night?

Quality of Sleep

Good
Poor

Do you smoke?

Yes
No
Third Choice

I acknowledge by signing below that I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time. I agree with the Practice Policies and Client Informed Consent Vivire Wellness has put in place.
Client Signature_____________________________________ Date: ___________

Email *