Client Intake Form Name(Required) First Last Email(Required) Phone(Required)Birthday(Required) MM slash DD slash YYYY (Yes, I'm asking how old you are.) Face and SkinDescribe your skin type, what you are using and what you want to change the most ! When you look in the mirror what bothers you the most about your face?(Required) Describe your skin. What have you tried? What has worked and what hasn't worked? Is your skin sensitive? If yes, to what? Are you concerned about wrinkles and if so where? Are you concerned about sagging skin? What area bothers you the most? Are you concerned about your skin anywhere else? Hands ? Neck? What have you tried in these areas? Did it work? What else would you like for me to know? SleepThe purpose of this section is to identify your sleep patterns so we can concentrate what to do first. How many hours of sleep do you average per night?(Required) Do you wake up in the middle of the night? Do you have trouble falling asleep? Is this new for you? When did it start? Do you take naps? How often? MovementShare how you like to move and how often to build a better stronger body that looks and feels good! How often do you move?(Required) Move what's that? You mean like exercise? 1-3 times per day 4 or more What kind of movement or exercise do you like to do ? Do you have an injury that limits or stops movements? Prescription and over the counter medications.Are you taking any medications at this time? If so please list.(Required) Do you have any medical conditions? Do you take any vitamins or supplements? Please list . Foods and eating habitsLook and feel better by finding food that work for you! What food do you like to eat?(Required) Do you eat breakfast and what do you eat? What foods make you feel good ? What foods disagree with you or makes you feel bad? What happens when you eat those foods? StressLet's discover that causes stress and how your body handles it. What is your stress level rank from 1 to 5 with 5 is the most stressed.(Required) How do you manage your stress? Are you taking any medications to help? (over the counter or prescription) GeneralAnything else you want to share?
