Assessment - The Skin Whisperer 30 Min Session

Name

Email Address

Telephone

Street Address

City

State

Zip. Code

What concerns me the most about your skin? Really think about this... when you look in the mirror I want to know what concerns me the most and if I could change any one thing what would that be? Please be thorough with your description.

How would you describe how your skin feels? check all that apply: How would you describe how your skin feels? check all that apply: Dry to Very Dry Combination - Oily/ Dry Oily Large Pores Discoloration Blotchiness / Sun Damaged Spider Veins and Distended Capillaries Rosacea, Redness and Sensitivity Blackheads and Whiteheads Coarse, Rough, Uneven Skin Texture Age Spots - Face and/or Body

Have you ever had Cancer? Have you ever had Cancer? Yes No

If Yes If Yes Did your treatment include Radiation Did your treatment include Chemotherapy Did your treatment include both Radiation and Chemotherapy

Is the Cancer in Remission? Is the Cancer in Remission? Yes No

How would you describe your current stress level? How would you describe your current stress level? Low Medium High Severe

Are you currently under the care of a physician? Are you currently under the care of a physician? Yes No

If so may we ask for what condition?

Are you currently using any topical medications for any skin disorder? i.e., Retin-A or any cosmetic medications Are you currently using any topical medications for any skin disorder? i.e., Retin-A or any cosmetic medications Yes No

You selected yes, please provide your list ?

Do you have an active outdoor lifestyle or go to the tanning bed? Do you have an active outdoor lifestyle or go to the tanning bed? Yes No

How do you cleanse your skin and how many times a day do you do this?

What state do you live in?

What type of climate is part of your everyday experience? i.e., hot, humid, dry, windy, cold,

Do you wear foundation or make up base? Do you wear foundation or make up base? Yes No

would you like to be able to not have to wear a makeup foundation or base would you like to be able to not have to wear a makeup foundation or base Yes No

Do you take vitamins or supplements of any kind? Do you take vitamins or supplements of any kind? Yes No

If yes, If so, what do you do daily and how would you describe your digestion and overall elimination? This may seem like an odd question but it’s critically important to the cleansing and detoxification process of the skin and the body.

The information on this site is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. All content, including text, graphics, images and information, contained on or available through this web site is for general information purposes only. Sunshine Botanicals, LLC and/or Emily Fritchey makes no representation and assumes no responsibility for the accuracy of information contained on or available through this web site, and such information is subject to change without notice. You are encouraged to confirm any information obtained from or through this web site with other sources, and review all information regarding any medical condition or treatment with your physician. NEVER DISREGARD PROFESSIONAL MEDICAL ADVICE OR DELAY SEEKING MEDICAL TREATMENT BECAUSE OF SOMETHING YOU HAVE READ ON OR ACCESSED THROUGH OUR APPOINTMENT OR THIS WEB SITE. The information on this site is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. All content, including text, graphics, images and information, contained on or available through this web site is for general information purposes only. Sunshine Botanicals, LLC and/or Emily Fritchey makes no representation and assumes no responsibility for the accuracy of information contained on or available through this web site, and such information is subject to change without notice. You are encouraged to confirm any information obtained from or through this web site with other sources, and review all information regarding any medical condition or treatment with your physician. NEVER DISREGARD PROFESSIONAL MEDICAL ADVICE OR DELAY SEEKING MEDICAL TREATMENT BECAUSE OF SOMETHING YOU HAVE READ ON OR ACCESSED THROUGH OUR APPOINTMENT OR THIS WEB SITE. YES, I ACCEPT NO, DO NOT ACCEPT