Skincare Consultation Name Email Address Birthday Allergies | Medication | Supplements Current Health (Diagnosed Conditions, Lifetsyle, Stress Levels, Anxiety...) Health History Current Skincare Routine & Treatments Previous Skincare Routines & Treatments How Would You Describe Your Skin (Appearance, Texture, Response to heat or products) Any Redness? Any Redness? Temporary Permanent None Texture Texture Dry & Flaky Taut & Tight Oily Normal Appearance Appearance Pigmentation Reddening Dull Open Pores Slack / Loss Of Tone Broken Capillaries Dark Shadows - Eyes Puffiness - Eyes Environment (Where Do You Spend Most Of Your Time? | Tick all that apply) Environment (Where Do You Spend Most Of Your Time? | Tick all that apply) Indoors Outdoors Hot Climate Cold Climate 5 + 9 = Submit