BeResilient Beauty
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Personal Information:
Full Name
Date of Birth
/
Month
/
Day
Year
Date
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Mailing Address
Skin Information:
Primary skin concerns or goals
Skin type (dry, oily, combination, sensitive)
Do you experience breakouts, redness, or irritation?
Diagnosed skin conditions (e.g., acne, eczema, rosacea)
Recent cosmetic procedures or treatments
Current skincare products (brand + product)
Allergies or sensitivities
Health & Lifestyle
Pregnant, nursing, or experiencing hormonal changes? ☐ Yes ☐ No
Current medications or supplements:
Current medications or supplements
Diet and water intake description
Average sleep (hours per night)
Stress level: ☐ Low ☐ Moderate ☐ High
Stress level:
☐ Low ☐ Moderate ☐ High
Average sleep (hours per night):
Diet and water intake description:
Sun exposure frequency: ☐ Rarely ☐ Occasionally ☐ Frequently
Do you use sunscreen daily? ☐ Yes ☐ No
Health & Lifestyle
Type option 8
Do you use sunscreen daily? ☐ Yes ☐ No
If yes, what kind?
Do you use sunscreen daily? ☐ Yes ☐ No
Do you smoke, vape, or consume alcohol regularly? ☐ Yes ☐ No
Do you smoke, vape, or consume alcohol regularly? ☐ Yes ☐ No
If yes, what kind?
Do you smoke, vape, or consume alcohol regularly? ☐ Yes ☐ No
Additional Notes or Comments
Acknowledgment:
By completing this form, you acknowledge that all information provided is accurate to the best of your knowledge.
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