Kristina Holey Consultation Questionnaire

Please complete this new client intake form prior to your scheduled appointment. This information is confidential and helpful in understanding you, your skin, and how to offer the best skin health guidance. This form takes up to 20 minutes to complete and must be completed in one sitting as it cannot be saved. We are grateful for the opportunity to provide you with customized advice and support for optimal skin health, and we look forward to working with you!

Full Name *

Email *

Phone Number

Where are you located? *

Date of Birth *

Weight *

Height *

What are the main goals/changes you would like to see in your skin? *

What are the main goals/changes you like to see in your overall health? *

Skin: Current AM/PM regimen; including all products (skin care + makeup) and brands, in order of use - please also explain if you like the product and how your skin feels after use: *

Skin: Do you enjoy your current AM/PM regimen? *

Skin: Do you wear sunscreen? Brand/SPF *

Skin: Describe the condition of your skin - Please be as specific as possible: What does your skin look and feel like in the AM? *

Dietary: Typical Diet - Be as specific as possible, including the hours of the day you typically eat these foods. Please also list fats that you cook with and any foods you snack on throughout the day: *

Dietary: Do you experience signs of irregular blood sugar such as hypoglycemia, feel dizzy when you stand up, or extremely fatigued? How is your energy throughout the day? Do you experience any gas/nausea/bloating after eating sweet foods, even natural sugars ex. fruit? *

Dietary: What is your appetite like? When are you the most hungry - morning, afternoon, evening? Do you experience cravings? What is your biggest meal of the day? Are there any foods/food groups you avoid or limit and why? *

Dietary: On average how much water do you drink each day? Other beverages you consume regularly? *

Dietary: Do you drink caffeine? If so, when and how much: *

Dietary: Supplements/Vitamins: What do you take, when, and what quantities (include brands): *

Dietary: Do you take any over-the-counter drugs or prescription medications? If so, please list: *

Dietary: In the past, have you taken a lot of antibiotics, as a child or young adult? *

Dietary: Do you have any known allergies? *

Dietary: Do you smoke? How many cigarettes per day? *

Digestion: Do experience any frequent digestive symptoms - bloating, gas, abdominal pain, heartburn/acid reflux? Do you notice if it’s triggered by certain foods? *

Digestion: How regular are your bowel movements? Do you frequently experience constipation or loose stool (or both/alternating)? Have you observed any abnormalities in your stool - undigested foods, color changes, stool that floats, particularly foul smell? *

Digestion: Do you experience frequent headaches? If so, how often and when during the day? Do you frequently take pain medications? *

Sleep: How many hours of sleep do you get on an average night? What time do you generally go to bed and wake up? *

Sleep: Do you have any issues with sleep - hard to fall asleep, waking up often (at what time/s), waking too early in the morning, hard time falling back asleep? Please explain: *

Sleep: Are you rested when you wake up? How is your overall energy and at what time of the day do you generally feel your best? *

Exercise: Is your lifestyle active? *

Exercise: Do you exercise regularly? If so, what kind/s and how often? *

Exercise: What does your skin look like after exercise? If you are flushed, where is most of the redness- on the cheeks or lower portion of the face? How long until it subsides? *

Exercise: Do you sweat easily? *

Aside from physical activity, does your overall body temperature generally run warm or cool? What type of temperature or season do you most prefer? *

Do you often feel thirsty? *

Do you experience night sweats? Do you flush easily? *

Do you experience cold hands/feet regularly? *

Hormonal: How many days do you bleed? Would you describe your flow as light or heavy? Any clots? *

Hormonal: Do you experience any PMS symptoms (breakouts, cravings, bloating, mood swings, breast tenderness)?If so, at what part during your cycle do you experience these symptoms? *

Hormonal: How does your skin fluctuate throughout your cycle? *

Hormonal: Do you take Birth Control or any other birth control methods (ex. IUD, ring, etc.)? Have you ever in the past- if so, when and what type, for what duration? *

Do you have low libido? *

Have you had any pregnancies or births? How many and when? *

Are you trying to conceive? *

Medical: When did you last see a primary physician? *

Medical: Have you had any recent blood work? What were the results? *

Medical: Please list any medical conditions you have and the date/s of diagnosis: *

Medical: Have any members in your immediate family been diagnosed with any health conditions, please list: *

Lifestyle: Travel: How often? *

Lifestyle: Please rate your level of stress, currently, and in the past: *

Lifestyle: What helps you relieve stress? *

Thank you! Anything else you would like to discuss or any questions you have for us? *

Please read through the consent form below and electronically sign in the space below

Kristina Holey is an integrated, informative, educative, and licensed aesthetician with the mission of providing self-healing tools to people for restoration of health and prevention of imbalances pertaining to the skin. The philosophy in which Kristina Holey bases her practice on has not been evaluated by the Food and Drug Administration or any medical association. Any of the products used in treatment have been carefully researched and approved for appropriate usage on the skin, as directed.

None of the information or products Kristina Holey suggests or uses are intended to diagnose, treat, cure or prevent any disease. For medical concerns, please consult your physician. Before making changes to your diet or lifestyle, please consult your physician.

Please DO NOT take the protocol* from Kristina Holey to substitute your medical treatment. The Kristina Holey approach is a long term, slow acting preventive therapy that includes diet, lifestyle changes along with facial massages, and topical and internal suggestions. IT IS NOT A MEDICAL PLAN. It is the therapy that slowly introduces healthy habits for improvement of health and helps in preventing risk of imbalance within the skin. It is NOT AN ALTERNATIVE PLAN for medical treatment.

*Please inform your physician about your new protocol before you incorporate changes to your diet and lifestyle.

Kristina Holey does not intend to diagnose, treat, cure or prevent any disease.

Kristina Holey Studio is NOT a medical facility or provides emergency services.

Please call your physician, medical facility or emergency services for ALL medical complaints.

_______________________________________________________

Please read carefully and only electronically sign below if you are in full agreement with its contents.

I ---------------------------- confirm that I have understood the treatment that I am to receive and confirm that I am willing to proceed without confirmation from my own GP or Consultant. I understand that some products used for skincare may be inappropriate for usage during pregnancy and it is my responsibility to inform Kristina Holey if I should fall pregnant while under her care. I will also inform Kristina Holey of any allergies or restrictions so that the treatment may be tailored to my needs. I do not expect Kristina Holey to anticipate any reactions topically from product usage. I wish to rely on Kristina Holey to exercise judgement during the course of the treatment and trust those to be in my best interest.

Full Name *

I hereby indemnify Kristina Holey against any adverse reaction sustained as a result of the treatment and agree with the above terms. *

Questionnaire Complete

Thank you! This is confirmation we have successfully received your answers.

Please schedule your consultation day/time here if you haven't already.

Thanks,

Team Marie Veronique

Questionnaire Complete

Thank you! This is confirmation we have successfully received your answers.

Please schedule your consultation day/time here if you haven't already.

Thanks,

Team Marie Veronique

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Sunscreen

Don’t get burned—know your sunscreen.

Safe protection from UV exposure reduces risks of skin cancer and prevents unnecessary signs of aging. Our sunscreens shine.

Rated #1 in EWG’s 2014, 2015 & 2016 Sunscreen Guide.

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