Astrology Meets Skincare Intake Form
Welcome to your Glow & The Chart experience. Please complete this form thoroughly so your consultation can be personalized to your skin, wellness, and energetic patterns.
Personal Information
Full Name
*
First Name
Middle Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Birth Chart Information
Date of birth
*
-
Month
-
Day
Year
Birth Time:
(If known) If your birth time is unknown, please estimate if possible
Birth City & Country:
*
Skin Concerns
What is your #1 skin concern right now?
*
Acne
Hyperpigmentation
Eczema
Dryness
Fine lines / aging
Sensitivity
Inflammation
Texture / congestion
Hormonal breakouts
Uneven skin tone
Other:______________________________________
How long have you been experiencing this concern?
What areas are most affected?
*
Forehead
Cheeks
Chin / jawline
Nose
Neck
Chest
Back
Other: ___________________________________________
Type a question
How would you describe your skin?
*
Oily
Dry
Combination
Sensitive
Acne-prone
Mature
Reactive
Current Skincare Routine
What skincare products are you currently using?
Cleanser:
*
Toner / Mist:
*
Moisturizer / Serums:
Sunscreen:
*
Prescription products or treatments:
*
Have you had professional facials before?
*
Please Select
Yes
No
If yes, what type?
*
Wellness + Lifestyle
How much water do you drink daily?
*
Less than 32 oz
32 - 64 oz
64 - 100 oz
More than 100 oz
How would you describe your stress level?
*
Low
Moderate
High
Very high
How many hours of sleep do you average nightly?
*
Less than 5
5-6
7-8
8+
How many bowl movements do you have daily?
*
3
2
2-3
1-2
1
I may skip a day
A week
Which foods do you consume frequently?
*
Dairy
Fried foods
Processed foods
Sugar
Seafood
Alcohol
Caffeine
Fast food
Plant-based foods
Fresh fruits & vegetables
Additional notes: snacks, deserts, etc.
*
Do you notice foods affecting your skin?
*
Yes
No
Unsure
Astrology + Energy
Have you ever had a birth chart reading before?
*
Yes
No
Do you know your Sun Sign?
*
Moon Sign?
*
Rising Sign?
*
Are you familiar with Ayurveda or Doshas?
*
Yes
No
Do you know your Dosha type?
*
Vata
Pitta
Kapha
Unsure
Which best describes you currently?
*
Overworked / overstimulated
Emotionally stressed
Burned Out
Low energy
Seeking balance
Wanting to Glow from within
Goals + Intentions
What would you like to improve most after this consultation?
*
What does "healthy glowing skin" mean to you?
*
Is there anything else you would like me to know before your session?
*
Signature
*
Submit
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