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Start Here
Start Here
Free Skin Consultation
Holistic Skincare Mentoring
The Jamele Welcome Facial
Skin-fit Boot Camp
FAQs
Our Story
Treatments
Jamele Treatments
FACIAL SPECIAL (AUTUMN OFFER)
FACIAL/MASSAGE COMBO DEAL
Facials & Pampering
Body & Massage
Hand & Foot Care
Grooming Essentials
Make-up Sessions
‘For Him’ Treatments
Visiting Consultants
Products
Jamele Products
Dermaviduals
Environ
Janesce
Joyce Blok
Jane Iredale Skincare Makeup
Bestow Beauty
Skin Vitality Value Pack
Gifts & Rewards
Gifts & Rewards
Buy Gift Vouchers Online
Skin Care Wisdom
Blog
SHOP
Contact
Holistic Skin Consultation
jamele_managewp
2017-06-02T10:00:19+13:00
Your Skin is a Reflection of Your Life
Step 1 of 14
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At Jamele Skincare, we take a holistic approach to treating skin challenges, drawing on the best that nature and science have to offer us. We believe that your skin is a reflection of your life. By getting a picture of your diet, lifestyle, skin history and stressors, we can identify the things that are stopping you from having the clear, soft, beautiful skin you hope for. We’re not here to judge you, we’re here to partner with you in your skin transformation journey.
Shelley Foster | Jamele Skincare Director
LET'S GET STARTED!
First Name
*
Last Name
*
Best Contact Number
*
Date of Birth
Date Format: DD dash MM dash YYYY
Email address
*
Address
PART ONE | THE SKIN YOU’RE IN
What is your skin type (if known)?
How would you describe how your skin looks and feels?
Does your skin have any of the following characteristics?
Please select the most appropriate option for each question.
Oiliness
*
None
Low
Mod
High
Dry, tightness
*
None
Low
Mod
High
Blackheads or whiteheads
*
None
Low
Mod
High
Scaling or cracking
*
None
Low
Mod
High
Itchiness in scalp
*
None
Low
Mod
High
Itchiness in eyebrows
*
None
Low
Mod
High
Skin sensitivity and allergies
*
None
Low
Mod
High
Red, flushed nose
*
None
Low
Mod
High
Red, flushed cheeks
*
None
Low
Mod
High
Eczema (behind elbows and knees)
*
None
Low
Mod
High
Eczema (on the face)
*
None
Low
Mod
High
Eczema (on the body)
*
None
Low
Mod
High
Dull, congested skin on face
*
None
Low
Mod
High
Pimples (on face)
*
None
Low
Mod
High
Pimples (on chest and back)
*
None
Low
Mod
High
Pimples (under the jawline)
*
None
Low
Mod
High
Tender, deep pimples that are slow to heal
*
None
Low
Mod
High
Dry/flaking eyelids
*
None
Low
Mod
High
Dry/flaking skin around nose or mouth
*
None
Low
Mod
High
Red/irritated skin around nostrils
*
None
Low
Mod
High
Psoriasis
None
Low
Mod
High
How long have you experienced these problems with your skin?
PART TWO | HOW YOUR SKIN AFFECTS YOUR LIFE
Please describe what impact your skin challenges have on:
Your daily life?
*
Your relationships?
*
Your confidence and emotional well-being?
*
On a scale of 1-10 how important is it to you to change your skin?
*
1
2
3
4
5
6
7
8
9
10
Please comment on why you chose the number you did.
*
On a scale of 1-10 how willing are you to make changes in order to achieve beautiful skin?
*
1
2
3
4
5
6
7
8
9
10
Please comment on why you chose the number you did.
*
PART THREE | YOUR SKINCARE REGIME
Please list all of the skincare products that you use each day, including sunscreen.
In the morning
*
In the evening
*
Do you currently, or have you ever used any products containing Retin A, Retinol, Glycolic Acids, AHA’s or Hydroquinone?
*
Yes
No
Please give details
Do you take any medication or pharmaceutical products for your skin?
*
Yes
No
Please list your medication and what it was prescribed for
Have you ever prescribed or taken Roaccutane/Isotane?
*
Yes
No
What was this prescribed for?
How long did you take it for?
When did you stop taking it?
What type of beauty therapy treatments do you have and how often?
Have you ever had any laser or IPL treatments?
*
Yes
No
Please provide details.
Have you ever had chemical peels or microdermabrasion treatments?
*
Yes
No
Please provide details.
Anything else to add?
PART FOUR | GETTING TO KNOW YOU
Your Work Life
What is your occupation?
Which of the following best describes your situation.
*
I work full-time
I work part-time
I am retired
I work as a full time parent.
I am self-employed/own a business
I am a student
How many hours do you work per week on average?
*
Do you sometimes work night shifts?
Yes
No
Please describe your physical work environment. (i.e. Do you work mostly inside or outside? Do you work in air-conditioning?)
On a scale of 1-10, how stressful do you find your job? (10 being extremely stressful and 1 being not at all stressful.)
*
1
2
3
4
5
6
7
8
9
10
How does this stress impact your life?
Do you work in a competitive environment?
Yes
No
Please tell us a bit about this.
Anything else to add?
YOUR HOME LIFE
Which suburb do you live in?
Do you have a partner?
Yes
No
Do you have children?
Yes
No
What are your children’s ages?
How many children live at home with you?
What heating do you use in your home?
What hobbies do you have?
What commitments do you have beyond family and work?
On a scale of 1-10, how stressful is your home life? (10 being extremely stressful and 1 being not at all stressful.)
1
2
3
4
5
6
7
8
9
10
How does this stress impact your life?
Anything else to add?
YOUR EXERCISE PATTERNS
Do you do regular physical exercise?
Yes
No
Please describe your exercise routine in a typical week (i.e. what type of exercise and how often)
Do you lift weights?
Yes
No
Do you do high-energy workout classes?
Yes
No
Do you swim in chlorinated water?
Yes
No
How often do you exercise to the point of sweating?
Anything else to add?
YOUR HEALTH AND WELLBEING
How would you describe your current state of health?
How would you describe your energy levels?
What is your height?
What is your weight?
Do you suffer from any of the following?
High blood pressure
*
Yes
No
Please provide details.
Low blood pressure
*
Yes
No
Please provide details.
High cholestoral levels
*
Yes
No
Please provide details.
Diabetes
*
Yes
No
Please provide details.
Family history of diabetes
*
Yes
No
Please provide details.
Epilepsy
*
Yes
No
Please provide details.
Claustophobia
*
Yes
No
Please provide details.
Constipation
*
Yes
No
Please provide details.
Irritable Bowel Syndrome
*
Yes
No
Please provide details.
Urinary infections
*
Yes
No
How often do you have them?
Menstrual problems
*
Yes
No
Please provide details.
Gall bladder disorders
*
Yes
No
Please provide details.
Thrush
*
Yes
No
Please specify how often
Candida
*
Yes
No
Please provide details.
Asthma
*
Yes
No
Please provide details.
Recurring colds and viral infections
*
Yes
No
Please provide details.
Hay fever
*
Yes
No
Please provide details.
Allergies to grasses/animals
*
Yes
No
Please provide details.
Low energy levels
*
Yes
No
Please provide details.
Have you had any operations in the last two-three years?
*
Yes
No
Please provide details.
Have you had any skin cancers?
*
Yes
No
Please provide details of skin cancer treatment or surgery.
Please list any medications you take and what they are for.
Do you experience any side-effects from your medications?
Yes
No
Please give details:
Have you ever had an anaphylactic reaction?
*
Yes
No
Please give details:
Have you recently been on antibiotics?
*
Yes
No
For what reason?
Are you on the contraceptive pill?
*
Yes
No
How long have you been taking it for?
If not, have you been on the pill in the past?
*
Yes
No
When was this, and how long for?
*
Are you using any other form of contraception?
Yes
No
Please provide details
Are you menstruating regularly?
Yes
No
Please provide details
Are you pregnant?
*
Yes
No
If so, how many months?
Are you hoping to fall pregnant in the next three months?
*
Yes
No
Please give details.
Are you breast-feeding?
*
Yes
No
Please give details.
Do you smoke cigarettes?
*
Yes
No
How many do you smoke on a typical day?
How often do you experience flatulence?
Often
Occasionally
Never
How often do you experience bloating?
Often
Occasionally
Never
How often do you experience indigestion?
Often
Occasionally
Never
Do you have trouble with skin rashes?
*
Yes
No
Please provide details.
What are you most grateful for in your life currently?
What are you least grateful for in your life currently?
Anything else to add?
PART SIX - YOUR DIET AND LIFESTYLE
Do you have any known food allergies or intolerances?
Do you drink alcohol?
*
Yes
No
What type? (beer, wine, spirits)
*
How many alcohol free days do you have a week?
*
What nutritional or vitamin/mineral supplements do you take?
Please outline how long you have been taking them, who prescribed them and for what reason.
YOUR WEEK-DAY DIET
List honestly and as accurately as possible what you eat and drink (including water) during a typical Monday-Friday work week.
Breakfast
Select Time
7.30am
8.00am
8.30am
9.00am
9.30am
10.00am
Please provide details.
*
Mid Morning
Select Time
10.30am
11.00am
11.30am
12.00pm
Please provide details.
*
Lunch
Select Time
12.30pm
1.00pm
1.30pm
2.00pm
2.30pm
Please provide details.
*
Mid Afternoon
Select Time
3.00pm
3.30pm
4.00pm
4.30pm
5.00pm
5.30pm
Please provide details.
*
Dinner
Please select
5.30pm
6.00pm
6.30pm
7.00pm
7.30pm
8.00pm
8.30pm
9.00pm
Please provide details.
*
Supper
Select Time
9.00pm
9.30pm
10.00pm
10.30pm
11.00pm
11.30pm
Please provide details.
*
YOUR WEEKEND DIET
List honestly and as accurately as possible what you eat and drink (including water) during a typical weekend.
Breakfast
Select Time
7.30am
8.00am
8.30am
9.00am
9.30am
10.00am
Please provide details.
*
Mid Morning
Select Time
10.30am
11.00am
11.30am
12.00pm
Please provide details.
*
Lunch
Select Time
12.30pm
1.00pm
1.30pm
2.00pm
2.30pm
Please provide details.
*
Mid Afternoon
Select Time
3.00pm
3.30pm
4.00pm
4.30pm
5.00pm
5.30pm
Please provide details.
*
Dinner
Select Time
5.30pm
6.00pm
6.30pm
7.00pm
7.30pm
8.00pm
8.30pm
9.00pm
Please provide details.
*
Supper
Select Time
9.00pm
9.30pm
10.00pm
10.30pm
11.00pm
11.30pm
Please provide details.
*
“I am open and willing to making changes to my diet in order to change my skin.”
Please describe your personal response to this statement. Is this true for you? What thoughts and feelings does it evoke?
*
How did you hear about the Jamele Holistic Skincare Consultation?
*
Are you happy to receive our e-newsletter with skin education, product/treatment updates and specials?
*
Yes
No
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