Client Consultation Card

Client Name and Surname

Client Information
Birthday D D M M C C Y Y Age Occupation Language

Address
Would you like to receive
Annique information and VIA VIA VIA VIA
Mobile E-mail special offers? SMS EMAIL FB WHATSAPP

Lifestyle Information Medical Information Cortisone Y N

How many times per day does the client: Pregnant/Breastfeeding Y N
Y N
Other
Fever Blisters Is the client
Smoke Pacemaker Y N
Cardio Disease (specify) interested in
Consume Alcohol Metal Plates or Pins Y N Y N Weight-loss?
Thyroid Gland Complications
Take Vitamins and Minerals Cancer (specify) Y N Y N
Epilepsy
Drink Caffeinated Drinks Retin A or Roaccutane Y N Y N
Note
Diabetes
Consume Water Eczema / Skin Inflammation Y N Y N
Antibiotics (past two weeks)
Exercise Osteoporosis Y N Y N
Contact Lenses
Contraceptive Y N
Sun Exposure
Medication

Client Allergies Body & Skin Concerns

Have you ever had a reaction to any of the following: Other (specify) Skin Type
Sensitive Normal Combination Dry Oily

Vitamin C / Citrus Y N Soya Y N Main Skin Concerns

Vitamin A Y N Shellfish / Iodine Y N Body Concerns
Cellulite Stretch Marks Fatty Deposits Sagging skin

Fruit Acids Y N Eyeline / Mascara Y N Nail Condition
 Y N Product
Skin Care Information Sun Protection
Cleanser Y N Product Eye Cream/Gel Y N Product
Freshener Y N Product Serum/Booster Y N Product
Day Cream Y N Product Exfoliator Y N Product

Night Cream Y N Product Mask Y N Product

How does your skin feel? AM PM

Other Products

Client Declaration
I, _______________________________________ hereby declare that the above information is correct and true. I also agree
that the Annique Consultant is not to be held liable for any injuries or adverse effects on my body or skin.

Signature ___________________________ Date D D M M C C Y Y

PRODUCTS SOLD/ Indicate problem areas

DATE COMMENTS Please indicate on Diagram problem
PRESCRIBED
areas by using the key below: A B
Breakout
Comedones/Blackheads D
Milia/Whiteheads C E
Oily Skin
Acne
F G
Sensitivity I
Broken Capiliaries
Dehydration
H J
Fine Lines
Wrinkles
Pigmentation
K
Other