Zanya Wellness
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Personal Details
Emotional & Mental Factors
Facial Assessment
Consultation for Hair
PERSONAL DETAILS
Name
Address
Date of Birth
Contact Number
Email
Occupation
Age Group
Under 20
20 - 30
31 - 40
41 - 50
51 - 60
61 - 70
70+
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EMOTIONAL AND MENTAL FACTORS
Stress Level
Sleep Pattern
Energy Levels
Work Life balance
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FACIAL ASSESSMENT
Skin Type
Normal
Dry
Sensitive
Oily
Combination
Skin Blemishes & Disorders
Erythema
Keloid
Lesion
Oedema
Papule
Pustule
Vesicle
Comedone
Milium
Open Pores
Broken Capillaries
Pigmentation
Sunburn
Skin Elasticity
Scars
Others
Medical Conditions If Any
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CONSULTATION FORM FOR HAIR
Condition of Hair
Virgin
Color Treated
Prelightened
Chemically Treated
Hair Type
Straight
Wavy
Curly
Hair Structure
Normal
Medium
Thick
Fine
Resistant
Length of Hair
Short
Shoulder Length
Below Shoulder
Midback
Upto Waist
Hair Density
Fine
Medium
Thick
Scalp Health
Normal
Oily
Dry/Flaky
Others
What Treatment Does the Client Require
Haircut
Styling
Colour
Prelightening
Straightening/Smoothering
T3 Hair Enzyme
Hair Spa
Treatment for Scalp & Hair
Head Massage
Regular Hair Care Routine Followed by Client
Shampoo
Conditioner
Styling Products
Others
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