Highland Essence, natural skin care products.

Highland Essence Consulation Form

In order to provide you with the correct product we will need you to answer the following questions about your lifestyle. All forms are completely confidential.

Client Details	(*) Denotes required field
* Name:
* Email address:
Postal Address:
Products interested in::

Client History
Have you had any of these health problems past or present?	Epilepsy Thyroid Diabetes Heart Problems
Can you list any medications or vitamins that you take regularly?	Medication: Vitamins:
Do you smoke?	Yes No
How would you describe your diet?	Healthy Mostly Healthy Unhealthy
How often do you exercise?	Always Occasionally Never
How many units of alcohol do you consume in a week?	1 to 3 4 to 6 6+	How many glasses of plain water do you drink daily?	1 to 3 4 to 6 6+
Do you get stressed or angry easily?	Always Occasionally Never	Have you had recent surgery?	Yes No
Before, during or just after your menstrual cycle do you feel	Angry Sad/Tearful Fine	Do you suffer from head aches or migraines?	Yes No
Are you taking oral contraception?	Yes No	Are you pregnant or trying to become pregnant?	Yes No
Are you menopausal	Yes No

Client Allergies
Have you ever had an allergy or reaction to any of the following?	Medicine Pollen Nuts Food Fragrance Fruit, please specify:

Cleansing Routine & Skin Type
Do you have a particular skin problem pertaining to your face?	Yes No	If yes please specify:
What type of skin care products are you currently using?	Soap Cleanser Facial washes Toner Exfoliate Moisturiser
Do you ever experience any of these conditions on you skin?	Flakiness Tightness Obvious Dryness Oily breakouts
Please be aware that the therapist requires these details in order for the correct treatment and products to be prescribed. Highland Essence cannot accept responsibility for any injury or reaction suffered by an individual which is attributable to not have given full and true answers to the consultation questions.
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