Constance Glow Intake Form

Client Intake Form

All information is held strictest confidence. At no given point is information disclosed or shared without client’s written consent. You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose.
Full Name*

First NameMiddle NameLast Name
Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date

MonthDayYear
Phone Number*
This is my:*
E-mail*
Occupation
Medications
Allergies
Client History
List daily routie: cleanser, toner, moisturizer, and prescription medicine for skin*
List specialty products: Mask, exfoliatior, clearasonic brush*
Where are your breakouts? Face or back. Forehead, cheeks, chin, etc.
Do you pop, pick or squeeze your pimples?
Are you using a daily facial scrub?
Are you currently under stress?
Do you suffer from one of the follwing:

AcneEczemaRosaceaIngrown hairsAging SkinDark marks/ HyperpigmentationDull skinDry flaky skinDark circles undereyesOther:
Do you consume the following:*

FruitsVegetablesFish, SeafoodMeats: Beef, Pork, Lamb, Chicken, Turkey, Etc.Dairy: Milk, Cheese, Butter, Yogurt, Ice Cream, etc.Caffeine: Coffee, Chocolate, Soda, etc.Hot spicy foodWhite sugars: Breads, Noodles, Rice, PotatoesDo you make smoothiesDo you juice your fruits and veggiesSweets: Cakes, Candies, Pies, etc.Alcoholic beveragesRestaurant FoodsHome-cooked mealsOther
What is your favorite food and snack?
Have you ever had a facial before? *
Have you ever incorporated Ayurveda into your life? *
Are you undergoing the follwing: Microdermabrasion, Chemical Peels, Retin-A treatments?
How many glasses of water do you consume daily?
How many times per day do you have a bowel movement?
How many meals do you eat per day? Do you skip meals? *
What are your skin care goals?*
List any other concerns that you would like to address
Should be Empty: