Cat Aiello | Virtual Skin Coach

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A BETTER YOU IN 1-2-3

1. Fill In The Detailed Form Below
This allows Cat to fully understand your skin, your lifestyle and your health.

2. Book Your Appointment

Use the Book Virtual Consult button (below form) to effortlessly pick your day and time to speak with Cat.

3. Enjoy Beautiful Skin

The fun begins! We give you everything you need to know about achieving the skin you desire.

Skin Coach Questionnaire

Full Name

Date of Birth

Phone

Any Allergies?

EPI PEN NEEDED?

Yes

ANY SENSITIVIES? e.g. strawberries or citrus

LIST OF ALL MEDICATIONS & DATE STARTED

VITAMINS YOU CURRENTLY TAKE

HOW MANY HOURS PER DAY DO U SPEND IN FRONT OF A SCREEN OR DIGITAL DEVICE?

WHAT IS YOUR DAILY COMMUTE LIKE?

HOW MANY HOURS OF SLEEP DO YOU GET PER NIGHT?

STRESS LEVEL (FROM 1-10)

DO YOU SMOKE? HOW MANY CIGARETTES PER DAY? HOW LONG?

EXERCISE? How often & what type?

ANYTHING ELSE YOU CAN ADD ABOUT YOUR LIFESTYLE?

GENERAL HEALTH? (Excellent, Good, Poor)

ANY AUTO-IMMUNE such as Lupus, Psoriasis, Type 1 Diabetes, Rheumatoid Arthritis, MS, Crohn’s, Celiac Disease, Vitiligo(destroys cell that produce pigment), Alopecia (the body attacks hair follicles)?

List all Skin Treatments received, including Botox AND/OR fillers.

Any reaction to a skin treatment or product? If Yes, please describe in detail.

LAST TIME received facial or skin treatment?

Hormone Replacement Therapy? e.g. Estrogen patch

Do you currently take birth control?

Yes

PREGNANT or NURSING?

Yes

USE SPF?

Yes

SEEING Dr. FOR ANYTHING?

Yes

SKIN CANCER?

Yes

KELOID SCARRING?

Yes

WHAT PRODUCTS ARE YOU CURRENTLY USING?

Yes

PLEASE LIST YOUR MORNING & EVENING SKINCARE ROUTINE IN DETAIL.

DO YOU NOW, OR IN PAST, USE ANY OF THE FOLLOWING?

Topical Vitamin C

Accutane

Skin Lightener, e.g. Hydroquinone

Vitamin A , e.g RetinA, Renova or Differin

IF USE ACCUTANE, LAST DATE USED

MAKEUP LINE YOU USE?

HOW WOULD YOU DESCRIBE YOUR LEVEL OF EVERYDAY MAKEUP COVERAGE?

ANYTHING ELSE YOU WOULD LIKE TO SHARE ABOUT YOUR SKIN?

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Book Virtual Consult

Enjoy 10% off Your First Order (for orders over $100)

Email:

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