Face HIIT Intake Form

Personal Information

First Name*

Last Name*

Age*

Birthdate

Email*

Contact Number*

Where do you currently live?

Medical History

Do you have any medical conditions or past facial surgeries/treatments? Please specify:

Do you have other issues like teeth grinding, jaw clenching, or headaches?

Skincare Routine

Describe your current MORNING skincare routine and which products are you using:

Describe your current NIGHT skincare routine and which products are you using:

Please share any additional skincare routine/practices:

Face Exercise Experience & Goals

Have you previously tried facial exercises or massages and what was your experience?

What are your goals? Any specific areas you feel need extra attention? (e.g., wrinkles, sagging, puffiness, dullness)?

What do you expect from the Face HIIT program (appearance improvement, stress reduction, etc.)?

On a scale from 1-10, how committed are you to consistently performing the exercises?

Please upload a recent, clear picture of your face, preferably in natural light:

Max. file size: 8 MB.

Overall Health Information

What are your wellness habits regarding food and hydration?

Do you crave sugar, coffee, cigarettes, or have any major addictions?

How is your sleep? Approximately how many hours do you get per night?

What is your stress level on a day to day/week to week basis? Please list stress management techniques you use.

Additional Comments

Aging is a natural and beautiful part of life. To stay focused on your true beauty and embrace this journey with positivity, think of a word or affirmation that uplifts and inspires you. Examples: "Confidence," "I am radiant," "Aging with grace," "Beauty at every stage," "Timeless beauty," etc..

Anything else you would like to share?