Formulario Facial / Corporal

Name and Last Name

Birth Date

Email

Telephone

Sex
MaleFemaleNon Binary/Other

Adress

Country

City

In which app do you prefer your consultation
WhatsappZoom

Reason for Consultation
—Please choose an option—FacialBody

[group Facial]

Have you ever suffered, or actually suffers from any of the next listed diseases, problems or habits, related to nutrition
Tummy Problems (reflux, heartburn, stomach ulcer)Constipation, DiarreaPain in bonesAlergies or asthmaVaricose VeinsHeadache or MigrainsDiabitis or Insuline ResistanceMuscular PainsHigh Blood PressureHypothirodismHeart ProblemsCancerHIVliquid retentionCoffee DrinkingSmokingControlled susbstances abusePhysical activity

Do you consume any prescribed medicine?
SíNo

Which of the next actions you oftenly make?
Have a daily skin routineVisited a professionalUse sunscreen dailyEat Healthy

Which of next foods do you prefer?
Fried FoodJunk FoodGreasy FoodCanned FoodProcessed Meats (sausages, bacon, etc)ChocolateAvocadoMayonnaiseSaucesVegetablesFruits

Skin problems that worry you
AcneExpression linesDark skin spotsPremature AgingDilated PoresGreasy SkinDry SkinScars

Send us a Face Picture, frontal part, without flash or make up

Send us a Face Picture, right part, without flash or make up

Send us a Face Picture, left part, without flash or make up

[/group]

[group Coroporal]

Have you ever suffered, or actually suffers from any of the next listed diseases, problems or habits, related to nutrition
Tummy Problems (reflux, heartburn, stomach ulcer)Constipation, DiarreaPain in bonesAlergies or asthmaVaricose VeinsHeadache or MigrainsDiabitis or Insuline ResistanceMuscular PainsHigh Blood PressureHypothirodismHeart ProblemsCancerHIVliquid retentionCoffee DrinkingSmokingControlled susbstances abusePhysical activity

Do you consume any prescribed medicine?
SíNo

Weight (in Pounds)

Height (in feet)

Shirt/Top Size
XSSMLXLXXL

Pants Size
X SSMLXLXXL

Reason(s) for consultation
Weight LossHabits change, eating planIncrease Energy LevelsDetox recipesCelulitisHealty food recipes

Frontal Full Frontal Body Picture, with extended arms (no face)

Back Full Body Picture, with extended arms (no face)

Left Full Body Picture, with extended arms (no face)

Right Full Body Picture, with extended arms (no face)

[/group]

I accept and understand the consultation, and assure that all the information in this document is true, real and don´t represents any risk to my health or to other person health. Autorize the esthetical consultation indicated by Karem Feris.