Consultation Form
If you would like to contact The Henley Clinic then please click here.
Client name:
Clients address:
Email address:

City:		Apt/unit:
Date of consultation:		Post Code:
Age:		Birthday:

Clients History

1.What temperature of water do you use to clense with?
cool water		warm water		hot water

2.Do you have any special skin problems pertaining to your face?
yes		no
If yes, specify?

3.Do you have any special concerns pertaining to your body?
yes		no
If yes, specify?

4.What types of skin care products are you currently using?
soap		toner		masque		clenser
mositurizer		scrub/peel		other

Female clients only
1.Are you taking oral contraception?
yes		no

Oil Secretion
1.Do you experience breakthrough oily shine, during the day?
yes		no

2. Do you experience skin break-outs?
yes		no

Moisture Hydration
1. How much water do you consume daily?

2. Do you take laxatives or diuretics?
yes		no

3. How many alcoholic beverages do you consume weekly?
1-3		4+

4. Do you ever experience these conditions on your skin?
Flakiness		Tightness		Obvious Dryness

5. If you sunbathe, do you use a sunscreen / sunblock on your skin?
yes		no

Capillary Activity
1. Do you burn easily in moderate sunlight?
yes		no

2. Do you blush easily when nervous?
yes		no

3. Do you have a tendency to redness?
yes		no

4. Have you ever suffered any sinus problems?
yes		no

Nerve Activity
1. Do you drink caffeinated beverages (coffee, tea, soft drinks)?
yes		no
How many daily?

2. Do you take any stimulants or slimming tablets?
yes		no

3. Have you ever had a reaction to any of the following?
cosmetics		medicine		AHAs
fragrance		sunscreens
Reaction to other?