Your Email
Your First Name
Your Last Name
Date of Birth
—Please choose an option—12345678910111213141516171819202122232425262728293031—Please choose an option—JanFebMarAprMayJunJulAugSepOctNovDec—Please choose an option—19301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015
Address
Phone Number
Emergency Contact Name
Emergency Contact Phone Number
Do you regularly exercise? YesNo
Are you pregnant? YesNo
Do you smoke? YesNo
On average, how many units of alcohol do you drink per week? 0-45-910+
Do you feel that stress is a problem for you? YesNo
Do you suffer from migraines/headaches? YesNo
Do you have any sinus problems? YesNo
Do you wear contact lenses? YesNo
Do you have any metal implants? YesNo
Are you taking any of the following? Retinol A/RenovaVitamin C productsAlpha hydroxy acidsAccutaneOther topical medications
Do you have a tendency to redness, rashes or hives? YesNo
Have you ever had any reactions to products? YesNo
Please give details of the reactions and which products.
Have you had any facial treatments within the last 5 days? YesNo
Please give details of the treatment(s).
Are you currently seeing a GP or other practitioner and/or taking any prescribed medications? YesNo
Please give details of any prescribed medications, and/or what you are seeing your GP/other practitioner for.
Do you have any allergies? (e.g. to nuts) YesNo
Please give details of your allergies.
Do you have any of the following conditions?
High blood pressure
YesNo
Low blood pressure
Any cardiovascular conditions
Epilepsy
Asthma
Diabetes
Cancer
Oedema/swelling
Dysfunction of the nervous system
Fever
Contagious or infectious diseases
Skin disorders
Recent cuts/abrasions/bruises
Scar tissue from surgery - within 2 years for major, or 6 months for minor
Please use this space to give further details if you checked any of the above boxes.
List any other medical condition that you have that is not listed above, or anything else you feel is relevant to your treatment.
I declare the information that I have given is true and correct and that, as far as I am aware, I can undertake treatment with this therapist without any adverse effects. I agree to the privacy agreement as found at goodbalance.life
I am happy to receive emails relating to Good Balance.
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