美容养生馆顾客咨询表格

Queen Beauty Centre美容養生館

Consultation Record美容顾客咨询表格NO __________

Personal Details 個人資料

Name顾客姓名Consultation date 咨询日期

contact no联系电话E-mail 电邮：

Date of birth 出生日期：_______________ Age年龄______________ sex性別_______

Address住址___________________________________ occupation 职业__________________

Height Wight marital status NO of children

身高____________CM体重__________KG 婚姻状况：________ 子女数个

Family doctor Doctor’s Tel

家庭医生医生电话

Medical History And Contra-Indications 病历和禁忌

Diabetes metal plates pins hepatitis allergy other

糖尿病金属片/固定钉肝炎过敏症其他

Later medicine Later surgery

最近之药物治疗：____________ 最近曾接受之手术_________

Whether need to eat medicine for a long time allergy to other food ?

是否需要长期服食药物？是否对某食物过敏

Life Style Insomnia Strain Busy Relax

生活形式失眠紧张繁忙休闲

Habit Beer Smoking Spice coffee 愛好饮酒吸煙调味料咖啡The gastrointinaltract Difference The general Good

胃肠道差一般良好Excretion Difference The general Good

排泄差一般良好

Sleep Difference The general Good

睡眠差一般良好

Skin Analysis皮肤分析

Skin moisture Poor Average Good、

皮肤湿润度：不足部位良好

Skin secretion Poor Average Good、

皮肤分泌：不足部位良好

pores of the skin Average sensitive Very sensitive

皮肤一般敏感非常敏感

Elasticity Poor Average Good、

皮肤彈性較差一般良好

Lines supenficial lines Skin Colour The Skin is black

皺紋表面皺紋肤色皮肤黑