Health Assessment

Full name*

Email*

Check In

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Check Out

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1. How would you describe your diet?*

Balanced Average Poor

2. How much water do you drink per day?*

1 Lt More Less

3. How often do you exercise?*

Weekly Daily Never

4. Do you smoke?*

No 1-10 per day 10+

5. How would you rate your physical condition?*

Excellent Good Poor

Wellness History

Others (please specify):

2. Have you had any operations or injuries recently?

Yes No

If yes, please explain:

3. Are you allergic to, or do you have any sensitivity towards certain foods, medicines or other substances?

Yes No

If yes, please explain:

4. Are you pregnant or nursing?

Yes No

5. Do you wear contact lenses?

Yes No

Skin Care

2. Are you currently concerned with any of the following?

Others (please specify):

3. Which product range are you currently using?:

COVID19

1. Have you traveled to a country with a high number of COVID-19 cases?*

Yes No

2. Have you been exposed to anyone with a lab-confirmed positive test for COVID-19, or anyone who is currently under mandatory quarantine for possible COVID-19 exposure?*

Yes No

3. Do you currently have, or recently had, a cough, shortness of breath, headache, GI symptoms such as diarrhea OR a fever of 38 degrees or more?*

Yes No