Alpha-H Australia - Anti Ageing | Acne | Pigmentation | Sundamage | Skin Care Solutions - Alpha-H

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What's all the Fuss About?

Due to a high demand in skin consultation's currently being performed, there may be a delay of up one week to receive a response. We do apologise for this and thankyou for your patience.

Client Consultant Card

For a customised programme specifically designed for your skin, please complete the form below and our fully qualified Beauty Therapist will recommend the right products for you!

Client Name:

Preferred Therapist:

Client Address:

City:

State:

Post Code:

Email Address

Home Phone:

Mobile Phone:

Work Phone:

Birthday:

/ /

How did you hear about us?:

Do you receive the Alpha Beauty e-Newsletter? Yes No

Alpha-H Skin Analysis

SKIN HISTORY

Do you have skin allergies?:

Yes No

Do you consider yourself to have sensitive skin?:

Yes No

Are you allergic to any specific product or ingredient ?:

Yes No

Do you ever experience...

Flaking?

Yes No

Tightness?

Yes No

Obvious Dryness?

Yes No

Do you experience breakouts?:

Yes No

In which area of the face?:

Does your skin...

Flush Easily?

Yes No

Feel Hot?

Yes No

Feel itchy or sting ?

Yes No

What concerns you about your skin?:

VARIOUS MEDICATIONS MAY AFFECT THE SKIN:

Health Concerns:

Concern:

Medication:

Concern:

Medication:

Concern:

Medication:

Are you taking any vitamins? :

Yes No

Are you pregnant or intending to become pregnant? :

Yes No

Skin Concerns:

Have you ever taken Roaccutane?:

Yes No

Have you ever taken any other skin medication?:

Yes No

Are you currently using any products containing...

Glycolic

BHA-Salicylic Acid

Vitamina A

Vitamin C

Have you had any of the following procedures ...	Plastic Surgery	Chemical Peel	IPL	Laser
	Microdermabrasion		Skin Cancer Removal

DIET & LIFESTYLE:

Is your diet balanced or unbalanced...

Low Fat

High Fat

Alcohol Consumption

High Sugar

How much plain water do you consume daily...

1 Glass

2 Glasses

3 Glasses

1 Litre

2 Litres or more

Do you have a problem with constipation?

Yes No

Do you smoke?

Yes No

Do you exercise regularly?

Yes No

Are you taking oral contraception?

Yes No

What would your stress level be?

Low

1 2 3 4 5 6 7 8 9 10

High

What results/improvements are you looking for?

SKIN CARE:

Which brands of skin care are you currently using?

Cleanser		Serum / Ampoules
Toner / Lotion		Mask
Exfoliant		Sun Block
Eye Cream		Make up Foundation
Day Cream		Specialty Product
Night Cream		Body Products