Facial Analysis Questionnaire

First name

Last name

Email

Phone

Address

Birthday

Month

Day

Year

Before You Begin

Did you review the Content under the Main Menu, Entitled Facial Analysis?

Yes

No

Do you now understand what to expect during a facial analysis, afterwards, and the protocol(s)?

If you answered yes, please indicate below:

Yes

No

If no is your answer, please go back and review this material before you go any further in this questionnaire.

Health and Medical

List all pharmaceutical & minerals/vitamins you take?

Do you have any medically confirmed health conditions? Do you suspect any yourself:

Do you have a known autoimmune disease?

Yes

No

If yes, please explain:

Do you have any BOTOX, facial tattoos (permanent eyebrows or other) or other medical aesthetic work done? Eyelash extensions? Please list:

Food and Hormones

What do you typically eat for breakfast, lunch, dinner and/or snacks? List all food cravings:

(Men & Women) Do you suffer from hormonal issues: PMS, Estrogen Dominance, Low Testosterone or hormonal acne?

Are you perimenopausal or suffer with Menopause hormone issues?

About You

Tell us about you, do you have a job, in a relationship, any children?

What's your stress level 1 to 10, with 10 being high?

Care to share what some of the known causes may be:

What's your primary beauty concern?

Explain the issue you would like for us to address:

Vaccines and Body Signs

Have you had any vaccines or antibiotics in the past 6+ years? If so, which ones and for what purpose?

Do your feet and/or hands tend to be colder, warmer, or neither? How about the end of your nose?

Do you have any wee little red spots on your chest, face, neck or other areas? We call them cherry angiomas.

Your tongue: If you stick it out do you notice if you have

A: White coating on the tongue

B: Or white/yellowish

C: And/or a bit slimy looking

In regard to the whiteness of your eyes. Do you have any yellowing at all in them? If so, where? Do you have any visible blood vessels in the eyes, bordering on looking like they may appear bloodshot? Have you noticed any eye "twitching"?

Do you struggle with constipation? Or do you have very wet bowel movements?

Do you normally wear glasses?

Yes

No

Do you have any unresolved childhood PTSD, or Trauma, generalized PTSD, or Anxiety that you want us to help in treating with our inclusion of the "Release" protocols?

Final Question

Is there anything else you would like for us to know?

Before You Begin

Health and Medical

Food and Hormones

About You

Vaccines and Body Signs

Final Question

Bluebird Natural Healing

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