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ZOOM Party - Customizing Questionnaire
Please complete the following questionnaire and submit. This document is best completed and viewed from a desktop.
*
Indicates required field
Full Name
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Date of Birth
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Address
*
Line 1
Line 2
City
State
Zip Code
Country
Email
*
Referred By
*
Phone Number
*
Cell/Mobile Phone Number
*
May I have permission to add you to our text promotions?
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YES
NO
Option 3
Your mobile phone may be subject to additional fees.
FREE Skincare Resource Guide, when you subscribe to my monthly newsletter. Would you like to subscribe?
*
Yes
No Thank you
What conditions would you like to improve about your skin? (Select all that apply)
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Acne
Fine Lines/Wrinkles
Uneven Tone/Texture
Enlarged Pores
Age Spots/Freckles
Hormonal Pigmentation
Dehydration
Dark Circles
Saggy Skin
Oily Skin
Blotchiness
List any additional concerns that you would like to improve:
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Have you tried any treatments to address your concerns? What has worked and what has not?
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Example: I want to improve my acne. I have tried BPO and it worked for a month, then a broke out worse than before the BPO.
How would you rate your general health?
*
Excellent
Good
Fair
Poor
Are you currently taking medications? IF YES, please list:
*
If not taking any, please indicate No
Are you currently taking supplements? IF YES, please list:
*
If not taking any, please indicate No.
FEMALE ONLY: Are you currently:
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Nursing
Pregnant
Planning to become pregnant
Have you experienced or currently experiencing any of the following:
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High Blood Pressure
Low Blood Pressure
Skin Bruising
Varicose Veins
Rosacea
Headaches
High Cholesterol
Dermatitis
Eye Infection
Anemia
Herpes Simplex
Broken Capillaries
Keloid Scarring
NONE OF THE ABOVE
Please comment on all marked above
*
Has a physical prescribed (currently or in the past) any of the following:
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Benzoyl Peroxide
Accutane
Retin-A
Differin
Hydrocortisone
Triluma
Tretinoin
Hydroquinone
Metrogel
Sulfur
Topical Steroids
Topical Antibiotics
NONE OF THE ABOVE
Have you ever had allergic reactions to any of the following (Select all that apply)
*
Aspirin
Grapes
Salicylates
Seafood or Iodine
Dairy (Milk)
Latex or Kiwi
Apples
Citrus
Berries
NONE OF THE FOLLOWING
List any known allergies:
*
If you have no known allergies, please indicate : NKA
Are you currently under a physical care?
*
YES
NO
Are you under a physicians care for any of the following conditions:
*
Cancer
Radiation Therapy
Diabetes
Eating Disorder
Asthma
Hepatitis
Epilepsy
Facial or Oral Surgery
Botox/Fillers
Lupus
Stroke
Thyroid Disorder
Cardiac Disorder
Endometriosis
Poly-cystic Ovaries
Hysterectomy
Osteoporosis
Menopause
NONE OF THE ABOVE
Please comment on all marked above
*
I understand that some skin conditions may require more than one treatment and home care products to achieve the desired results. Results cannot be guaranteed due to individual skin types and condition as well as compliance. I have acknowledged that all of the information provided by me is true and correct to the best of my knowledge.
The information I have given above is true and correct to the best of my knowledge.
*
Please type your full name to confirm.
DATE
*
Submit
Home
SAFETY Guidelines
SERVICES
Skin Wellness Coaching
eGIFT CARDS
First Time Clients
Skin Analysis Questionnaire
Contact Us
CONTACT FORM
JOIN MY NEWSLETTER
