Full Name *
Full Name
Phone Number *
Phone Number
Address
Address
What does it look like? Red, scaly, cracked, dry etc What does it feel like? Itchy, soft, hard, bumpy, smooth etc
Are you currently taking any medications? If so, what and for what period of time? Have you taken any medications in the past? If so, what and for what period of time?
What products are you using and what frequency? How long have you been using them for?
Grasses, products, food? How do these appear?
Times of the day, times of the month, stressful times, dietary changes etc?