FORM – BOOK YOUR CLASS – Naturalbeautyfacegym

Do you hold any facial tension in the following areas? JawsCheeksAround my eyesNeckI don’t really know

Which facial contours would you like to enhance? JawlineCheekBonesEyes

Which expression lines would you like to soften? Forehead frown linesNasal labial foldsLip linesLines around my eyes (crows’ feet)

What massage pressure would you feel comfortable with? Light to MediumMedium to Deep

Are you using any of the below facial tools at home? Guasha stoneJade rollerMini Flat Brush with smooth brass rollerSmooth double ball roller (yang)Flying DiscSingle Roller Yin yang (Roller with steel needles - Toothed bakelite sphere)Pick with yin rollI don’t have any tools

How does your skin generally feel? DryOilySensitiveNormal

How would you like your skin to look? RadiantHydratedYouthfulBlemish free

Do you currently have any or undergone any of the following? YesNo

Active skin conditions (acne, eczema, psoriasis or cold sores, broken skin) YesNo

Exposure to sun or sunbed/tanning stations in the last 3-5 days YesNo

Dermabrasion, Laser Resurfacing or Skin Peel in the last 2 months YesNo

Botox in the last 2 weeks YesNo

Facial fillers in the last 4 weeks YesNo

Facial surgical procedures or other procedures related to the face in the last 6 months YesNo

Rosacea YesNo

Applied any Topical Retinoid or Vitamin A in the past week YesNo

Othe YesNo

YOUR HEALTH

It is important that we understand your current health condition to check for any medical contraindications before having your workout.

Do you have a medical history of any of the following?

Diabetes YesNo

Cancer YesNo

Epilepsy YesNo

Autoimmune Disorders (ie; Active collagen or vascular diseases) YesNo

Cardiovascular Conditions (Thrombosis, Phlebitis, Hypertension, Hypotension, Angina, Pacemakers) YesNo

Keloid Scars YesNo

Shoulder or Neck Problems YesNo

Other YesNo

Do you have any of the following?

Allergies YesNo

Bacterial Infections (ie; Impetigo, Facial Boils, Conjunctivitis, Styes) YesNo

Metal implants, pins or plates in your face, or other dental implants YesNo

Others YesNo

Are you currently taking any photosensitive medications within the last 6 months( Roaccutane) YesNo

Pregnant YesNo

Breastfeeding YesNo

Others YesNo

YOUR LIFESTYLE

How often do you work out your body? DailyWeeklyMonthlyI only workout my face

I understand, have read and completed this questionnaire truthfully and agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that Natural Beauty Face gym is relying upon the information provided herein and withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. By signing below, I acknowledge that I am participating voluntarily and do not wish to seek the approval of my doctor before having this treatment. I agree to hold Natural Beauty Face gym entirely free from any liability, including financial responsibility for any injuries incurred. I hereby release, waive, discharge and covenant not to sue Natural Beauty Face gym for any claim or liability arising of or related to the Natural Beauty Face gym treatment(s) that I receive. I declare that I am of legal age and that I have carefully read and fully understand and agree to the above terms.

TELL US ABOUT YOURSELF