Your Name

Your Email

・What issue do you most want to address right now? Please describe in detail.

・How long have you had this issue?

・Have you in the past or are you currently being treated for any medical condition(s)?
yesno
If so please describe.

・Are you currently taking any medications, supplements?
yesno
If so please list them and how long you have been taking them.

・Do you have any allergies (foods, synthetic fibers, pollen, animals, etc.)?
yesno
If so please list them.

・Do you exercise or engage in physical activity regularly?
yesno
If so please list what kind of exercise/activity you do and how often you do it. (ex. “Jogging 3 times/week” or “Playing Soccer 2 times a month”, etc.)

・Do you have any experience with dance or rhythmic athletics? (yoga, pilates, hip-hop, etc.)
yesno
If so please list. (ex. “Did yoga 2x a week for a couple years”, etc.)

・How many meals do you eat in a day?

・Please describe in detail what you typically eat in a day.
(eg. Breakfast: buttered toast and coffee at home,
Lunch: sandwich/burger/bento with a soda from a fast food place or convenience store,
Dinner: steak and baked potato with 2 glasses of wine at a restaurant, etc.)

・Do you snack throughout the day? (This includes sweetened drinks, coffee with milk, etc.)　　
　yesno
If so please list the snacks. (ex. “Small bag of chips or some chocolate/candy in the afternoon”, etc. )

・Do you consume dairy products? (milk, yogurt, cheese, ice cream. sour cream etc.)
yesno　
If so please list what dairy products you consume and how often. (“A glass of milk every morning”, or “Something with cheese in it just about every day”, etc.)

・Have you ever dieted or fasted before?
　yesno
If so please describe the “type” of diet, the “period” that you dieted/fasted for, “how much weight you lost” and “whether or not you gained the weight back”.
(ex. “4 years ago I did a low carb diet for 3 months and lost 4kg, but gained back 5kg after stopping the diet” or “I tried intermittent fasting for a week and lost 1kg, and kept the weight off”, etc.)

・Do you or have you ever smoked cigarettes?　
yesno　
If so please describe the number of years you smoked and how many cigarettes/day.
(ex. “I smoked 1 pack/day for 10 years in my twenties” or “I smoke occasionally when drinking with friends”, etc.)

・Are there any foods that you feel would be difficult to go without, or would cause you stress if you were to abstain from?
(ex. yakiniku, steak, burgers, ramen, pizza/cheeses,milk, yogurt, ice cream, cake, sports/energy drinks, sugary foods/candies, beer/wine/alcoholic beverages, etc.)
yesno
If so please list the food(s) and the level of stress you think you would experience. (ex. “I absolutely cannot live without burgers” or “As long as I can have 1 beer a day I’ll be ok”, etc.)

・Do you go out drinking socially?　
yesno
　If so please list “how frequently”, “how much you drink” and whether it is “private or for business”
(ex. “I go out once a week with friends and have 3-4 drinks” or “I go out with clients a few times a month and drink quite a bit”, etc.)

・Do you watch TV?　
yesno
　If so please list how much TV you watch per day and what you watch.
(ex. “I watch an hour of the news every evening” or “I watch 2 hours of TV; variety shows, comedy and sports”, etc.)

・Do you watch YouTube, Netflix, Hulu etc.?　
yesno
　If so please list how much you watch per day and the types of things you watch.
(ex. “I watch a couple hours of Netflix every day, mostly action shows and dramas” or “2-3 hours of educational videos and documentaries on YouTube/day”, etc. )

・Do you use social media?
yesno　
　If so please list which “platforms” you use, “how frequently” you use them and “how active” you are.
(ex. “I use Facebook for my business everyday for 1-2 hours, and peruse Twitter for fun for an hour or so during the day” or “I am constantly on Instagram throughout the day, and post a couple times a week”, etc.)

・How many hours of sleep do you usually get each night and what time do you do to bed/wake up?
(ex. “I try and be in bed before 12am and get up at 7am, average sleep per night is 6 hours”, etc.)

・Do you usually feel refreshed in the morning when you wake up?
yesno

・Do you dream?　
yesno
If so please describe how frequently you dream and what kinds of dreams you have.
(ex. “I dream almost every night, mostly everyday type things”, or “Only once in a while, and I dream about other worlds and fantasy-type things”, etc.)

・How many members are there in your household and what is your living situation?
(ex. “I live together with my wife in an apartment”, or “I live with my 8 year old son and 12 year old daughter in a house and my husband is currently working overseas”, etc. )

・Do you have your own personal “space” at home? (study, garden, your own private room, etc.)
yesno
If so please list it.

・Are you currently working/employed?
yesno
If so please describe your occupation. (ex. “I am self employed as a Web Designer”, or “I work part-time as a consultant remotely for a small company”,etc.)

・How many hours do you work per week? (Including business travel time, overtime and work from home)

・How do you commute to work and what is your commute time each day?
(ex. “An hour each way by train”, or “Usually 3 hours round trip by car”, etc.)

・What level of stress do you experience from work, and what (if any) is the main source of the stress?
(ex. “I love my job but the hours are long and there’s a lot of overtime so it’s moderately stressful”, or “I feel a great deal of inter-personal stress/ pressure from clients”)

・On a scale of 1-10 how enthusiastic/how much do you enjoy you work/occupation?

・On a scale of 1-10 how stressful is your family life?

・Is there anything you do to relieve stress/recharge yourself?
yesno
If so please describe it.
(ex. “I take a trip to the mountains once a month to refresh”, or “I eat sweet foods/watch movies/sing when I’m stressed)

・Do you have a chance to get out into nature? (walking in a park, going to the beach, hiking in the mountains, etc.)
yesno
If so please describe where and how often.
(ex. “Once a week I go hiking in a nearby mountain”, or “I take a week off every summer and go to the beach with my family”, “I golf a couple times a month”, etc.)

・Are there any plants in your living space?
yesno
If so please list the “types of plants” and the “location”.
(ex. “A glass bottle moss garden on the kitchen windowsill”, or “A decorative potted plant in the entrance area”, “Flowers in a planter on our veranda”, etc.)

・Are there any pets/animals at home?
yesno
If so please list them.
(ex. “2 cats and a goldfish” or “A goat and a horse”, etc.)

・Do you wash your face everyday?
yesno
・What do you use to wash your face?
Please list the “name of the product” you use and “how often you wash your face”.
(ex. “I wash my face in the evening with Dove Facial Cleanser”, or “I splash water on my face in the morning and use soap to wash it in the shower at night”, etc.)

・What do you use to wash your body?
・How many times a day do you shower/bathe?　
Please list the “name of the product” and “how often you shower”.
(ex. “Regular body soap once in the evening”, etc.)

・How often do you wash your hair?
・What shampoo and/or conditioner do you use?
Please list “name of the shampoo/conditioner” you use and “how frequently you wash you hair”.
(ex. “I wash my hair everyday with Suave shampoo, no conditioner”, or “I wash with an organic shampoo, every other day”, etc.)

・Do you use any hair styling products? (gel, wax, etc.)
yesno
　Please “list the products” you use and “how often” you use them.
(ex. “I use styling gel everyday”, or “A couple times a month I use wax”, etc.)

・Do you dye your hair?
yesno
　If so please list “how often” you dye your hair and “what dye” you use.
(ex. “Once every 2-3 months I get my hair dyed at a hair salon” or “I dye my hair at home every couple weeks with hair dye from the pharmacy”, etc.)

・Do you use any cosmetic products? (foundation, mascara, eye-shadow, moisturizer, etc.)
yesno
　If so please list the “product name(s)” and “how often” you use them.
(ex. “Chanel foundation and eye-liner everyday” or “Shiseido mascara and moisturizer only, just about every day”, etc. )

・Do you use sunscreen?
yesno
　If so please list the “name of the product” you use and “where on your body” you use it.
(ex. “I use Badger Sunblock on my face and arms only when going to the beach”, or “I use Shiseido Suncreen on my face everyday”, etc.)

・Have you ever done any cosmetic/skin care treatments?（IPL・HIFU・Dermapen・Peelings・PRP・Botox・Fillers・Cosmetic procedures, etc.）
yesno
　If so please list the “treatments” and “number of times” you received them.
(ex. “I got a few Botox injections last year”, or “I did fractional laser treatment for acne about 2 years ago”, etc.)

・Is there any thing else that you would like to add? (requests, questions, comments, etc.)
yesno
Feel free to write anything!

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