Glow With Akanksha Pre-Consultation Form

Glow With Akanksha Pre-Consultation Form
Thank you for booking your consultation! Please fill this form 24 hours before your session so I can prepare your personalized skin assessment and routine.
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Personal Information
Full Name
Please provide your complete name as it appears on official documents.
Age
Your age helps us understand your skin's unique needs and recommend age-appropriate treatments.
Location
City and country information helps us consider climate factors affecting your skin.
Email ID
We'll send your personalized skincare plan and follow-up recommendations here.
Your Top Skin Concerns
Select up to 3 concerns that matter most to you. Understanding your priorities helps us create a targeted treatment plan that addresses your specific needs.
Common Concerns
Acne / Breakouts
Pigmentation / Dark spots
Tanning
Dullness
Sensitivity / Redness
Dryness / Flakiness
Additional Issues
Oily Skin / Shine
Uneven Skin Tone
Aging / Fine Lines
Large Pores
Post-Pregnancy Changes
Other concerns
We'll also ask how long you've experienced these concerns and whether you've been diagnosed with any skin conditions like eczema, psoriasis, rosacea, or dermatitis.
Understanding Your Skin Behavior
01
Post-Cleansing Feel
How does your skin feel 10 minutes after washing? This reveals your true skin type—from tight and dry to very oily.
02
Morning Texture
Your skin's morning state tells us about overnight oil production and hydration levels.
03
Sensitivity Patterns
Do you experience burning, stinging, redness, or irritation with new products? Understanding sensitivity helps prevent reactions.
04
Seasonal Changes
How your skin responds to different seasons—oily summers, dry winters, sensitive monsoons—guides year-round care.
Your Current Skincare Routine
A complete picture of your current products helps us identify what's working, what's not, and what might be causing issues. Please list everything you use—cleanser, toner, serum, moisturizer, sunscreen, and any active ingredients.
Current Products
List all products in your daily routine with brand names and key ingredients.
Recent Additions
New products added in the last 3 months and when you started using them.
Discontinued Items
Products you stopped using due to reactions or adverse effects.
Professional Treatment History
Previous professional treatments significantly impact your skin's current state and future treatment options. Understanding your treatment history helps us avoid complications and build on successful approaches.
Common Treatments
Chemical peels
Laser treatments
Hydrafacial
Microdermabrasion
Dermaplaning
PRP (Platelet-Rich Plasma)
Please describe any reactions or side effects you experienced after professional treatments.
Hormonal & Lifestyle Factors
Your skin is deeply connected to your internal health. Hormones, stress, sleep, and nutrition all play crucial roles in skin behavior and treatment outcomes.
Reproductive Health
Are you pregnant, breastfeeding, or trying to conceive? This affects product safety and treatment options.
Hormonal Issues
PCOS, thyroid disorders, and other hormonal conditions significantly impact skin health and treatment approaches.
Stress Levels
Chronic stress triggers inflammation and breakouts. Understanding your stress helps us address root causes.
Sleep Quality
Sleep is when skin repairs itself. Your sleep hours directly affect skin regeneration and healing.
Hydration
Daily water intake affects skin moisture, elasticity, and overall health. We'll assess your hydration habits.
Diet Triggers
Dairy consumption and specific foods can trigger breakouts. Identifying your triggers helps optimize results.
Sun & Screen Exposure
80%
UV Damage
Up to 80% of visible aging is caused by sun exposure
365
Daily Protection
Sunscreen should be worn every single day, regardless of weather
6+
Screen Time
Hours spent on screens daily can contribute to skin concerns
Understanding your sun protection habits and daily exposure to sunlight and screens helps us recommend appropriate protection strategies. We'll ask about your sunscreen usage frequency—daily, only outdoors, seasonally, or rarely—and how many hours you spend in sunlight or on screens each day.
Blue light from screens and UV exposure both impact skin health, contributing to premature aging, pigmentation, and other concerns.
Photo Documentation
Clear, well-lit photos are essential for accurate skin assessment. They allow us to analyze your skin concerns in detail and track your progress over time.
Front View
Face forward in natural light, neutral expression
Left Profile
Turn left, capture side view clearly
Right Profile
Turn right, capture opposite side
Close-Up
Detail shots of specific concern areas
Photography Tips: Use natural daylight, avoid filters, ensure your face is clean and makeup-free, and take photos in a well-lit room near a window.
Final Notes & Consent
Additional Information
Is there anything else you'd like me to know before our consultation? This is your opportunity to share any concerns, questions, or specific goals that haven't been covered in the form.
Your Consent
By completing this form, you confirm that all details provided are accurate and you consent to be contacted regarding your consultation and personalized skincare plan.
Your information is kept confidential and used solely to provide you with the best possible skincare recommendations.
Ready to transform your skin? Complete this form 24 hours before your session, and I'll prepare a comprehensive analysis tailored specifically to your unique skin needs and goals.
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