Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone Number
*
(###)
###
####
Email
*
Birth Date
*
MM
DD
YYYY
Age:
How would you describe your skin?
*
What is your hereditary background?
*
Other:
IF yes, please explain:
Other:
If yes, please explain:
Are you currently taking birth control pills or have an IUD?
Are you currently pregnant or breastfeeding?
Are you currently experiencing Perimenopause or Menopause?
Are you currently undergoing any hormone therapies or taking any infertility drugs?
If yes, please explain:
Current Medications (include over the counter)
Current Herbal Supplements and Vitamins
Alcohol
Never or Daily Intake, # of Years, Date Last Used
Caffeine
Never or Daily Intake, # of Years, Date Last Used
Tobacco
Never or Daily Intake, # of Years, Date Last Used
Drugs
Never or Daily Intake, # of Years, Date Last Used
Water
Never or Daily Intake, # of Years, Date Last Used
Sugar
Never or Daily Intake, # of Years, Date Last Used
Carbs/Yeast
Never or Daily Intake, # of Years, Date Last Used
Are you having at least one bowel movement per day?
Do you wear contact lenses or eyeglasses?
Have you had excessive sun exposure in the last few days?
Will you be having excessive sun exposure on a vacation or in the near future?
Are you in the habit of using tanning booths?
