Skip to content
Home
About
Medicine
General
Consultation & Treatment Information
Book a Session
Creative
Research
Contact
Book a Session
Submit a Testimonial
Terms and Conditions
Search for:
Cart
0
Toggle Navigation
Toggle Navigation
Home
About
Medicine
General
Consultation & Treatment Information
Book a Session
Creative
Research
Contact
Book a Session
Submit a Testimonial
Terms and Conditions
Search for:
Cart
0
TCM Cosmetic Therapy Intake Form
Please enable JavaScript in your browser to complete this form.
Name
*
First
Last
Email
*
What would you like to accomplish throughout your TCM Cosmetic Therapy?
How do you feel about how you look on a daily basis? Please rate on a scale of 1-10:
1- I feel excellent
2
3
4
5- I feel ok
6
7
8
9
10- I feel poorly
How does your feeling of how you look affect your life? Please rate on a scale of 1-10:
1- Positively
2
3
4
5- Neutral
6
7
8
9
10- Negatively
What aspects about how you look affect you most positively?
What aspects about how you look affect you most negatively?
How would you rate the following aspects of your face? Please rate on a scale of 1-10............ Overall Facial Appearance: LIFT
1- Excellent
2
3
4
5- OK
6
7
8
9
10-Poor
Overall Facial Appearance: TONE
1- Excellent
2
3
4
5- OK
6
7
8
9
10-Poor
Is there another Overall Facial Appearance aspect you would like to rate? If so, please note what that aspect is below:
How would you rate this Other Facial Appearance Aspect
1- Excellent
2
3
4
5- OK
6
7
8
9
10-Poor
Overall Skin Quality: Texture
1- Excellent
2
3
4
5- OK
6
7
8
9
10-Poor
Overall Skin Quality: Glow
1- Excellent
2
3
4
5- OK
6
7
8
9
10-Poor
Overall Skin Quality: Evenness
1
2
3
4
5
6
7
8
9
10
Forehead: Wrinkles
1- Excellent
2
3
4
5- OK
6
7
8
9
10-Poor
Glabella (between eyebrows): Wrinkles
1- Excellent
2
3
4
5- OK
6
7
8
9
10-Poor
Eyebrows: Lift
1- Excellent
2
3
4
5- OK
6
7
8
9
10-Poor
Eyes: Wrinkles
1- Excellent
2
3
4
5- OK
6
7
8
9
10-Poor
Eyes: Openness
1- Excellent
2
3
4
5- OK
6
7
8
9
10-Poor
Eyes: Clarity
1- Excellent
2
3
4
5- OK
6
7
8
9
10-Poor
Eyes: Puffiness
1- Excellent
2
3
4
5- OK
6
7
8
9
10-Poor
Cheeks: Lift
1- Excellent
2
3
4
5- OK
6
7
8
9
10-Poor
Cheeks: Tone
1- Excellent
2
3
4
5- OK
6
7
8
9
10-Poor
Jaw: Tone
1- Excellent
2
3
4
5- OK
6
7
8
9
10-Poor
Jaw: Definition
1- Excellent
2
3
4
5- OK
6
7
8
9
10-Poor
Neck: Wrinkles
1- Excellent
2
3
4
5- OK
6
7
8
9
10-Poor
Neck: Tone
1- Excellent
2
3
4
5- OK
6
7
8
9
10-Poor
Are there any other aspects of your face you would like to rate? Please list and rate them on a scale of 1-10:
Do you have a skincare regime?
Yes
No
Please briefly describe your process and what products you use?
How often do you follow it?
Have you received Botox, fillers, or other cosmetic enhancements?
Yes
No
If so, please describe what enhancement, when it was done, and where on your body:
Do you use any supplements or medications for cosmetic or facial concerns? If so, please list product and usage.
Is there anything else you would like to address in session?
Submit