Personal Consultancy With Danièle

For further information please email
info@danieleryman.com

Please fill the questionnaire before a consultation.
Your name*

Email*

Address (optional)

Age*

Gender*
Female Male
Skin condition and lifestyle: (Please tick ALL that apply to you) My Skin is:
Tired Dry Greasy Congested Sensitive Scarred (How obtained?) Swollen No skin tone I have fine lines around the eyes area I have dark circles around the eyes I suffer from poor circulation I have broken veins on my face I have allergy to certain products I suffer from Eczema, rash I suffer from Acne I have swollen areas on my face My skin burn easily in the sun
Aditional notes

Physical Condition:
Anxious or easily agitated Tire easily Stressful life style Suffer from Insomnia Smoker Worry for no reason Depressed easily
How much alcohol do you normally drink per week?

Your sense of smell: At what age did you first become conscious of aromas in your life?

How much do you depend on your sense of smell?
Not much Normal A lot
Have you ever suffered a loss of your sense of smell? Do you know why?

What is the first memory of smell you liked?

Why do you wear a fragrance?
To express yourself? To be noticed? It makes you feel good?
Do you wear a perfume depending on:
Time of day? Time of night? Occasion? Mood? Season?
Do fragrances change on your skin?
Yes No
Do they smell different after a while?
Yes No
Have you had a reaction to a perfume?
Allergy Headache
Aroma Preference: Which of the following smells of do you most like: (in order of preference) 1st

2nd

3rd

Which herb or flowers do you most like?
Lavender Lemongrass Rosemary Rose Gardenia Jasmine Tulip Lily of the Valley lemon Orange Pine Lilies
Any other herb or flowers you most like?

Are they any smells you don’t like?

Other Comments: