Please complete all required fields to the best of your ability. I will be in touch with follow up questions within 1-2 business days. Consultations are conducted Tu-Fr.

All client health information is confidential between holistic health consultant & client. 

Highest Health & Blessings to you.

-Amena

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Name *

First

Last

Email *

Email

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What part of the world are you in? *

list city & state/ country

Welcome to your Holistic Health Consultation! All questions are required fields. If something doesn't apply put n/a or not applicable. *Got it!

select got it to continue

What are your health issues and/or concerns? *

what conditions have you been diagnosed with, if applicable. please be as detailed as you need here

Tell me about your current diet / eating habits? *

carnivore, vegetarian, pescatarian etc

Do you have any food allergies? *

please list all foods you are allergic to

How much water H20 do you consume daily? *

Are you physically active? *

yoga, general exercise, swimming etc and how often

How many hours of nightly rest do you average? *

Are you on any medication? *

medications can interfere with our bodily functions, hair & scalp health so please list all medications pharmaceutical or herbal

How do you wear your hair – natural, relaxed, permed etc and do you have any hair and scalp concerns/issues? *

be as detailed as you like here

If yes to hair or scalp issues, list all products you are currently using for your hair care regiment. *

shampoos, conditioners, stylers and any other treatments and oils

How often do you shampoo & condition your hair? How often do you deep condition? *

n/a if you have no hair or scalp concerns. weekly, bi weekly, monthly…never

When is the last time you had your ends trimmed? *

n/a if you have no hair or scalp concerns

Do you color your hair? If yes, is it chemical or pure henna? how often and what brand(s)? *

n/a if you have no concerns. If color is done by a professional and brand is unknown that is ok but if you can find out it can be helpful in resolving issues

How do you style your hair majority of the time? *

n/a if you have no concerns. wash & go, twists, twists outs, braids, braid outs, blown dry, wigs, etc…

Do you heat style your hair? If yes, how often and is it blow dry only or flat iron/straightening comb? *

n/a if you have no concerns

Do you wear braid or twist extensions? If yes, how often do you wear them and how long do you leave them in on average? *

n/a if you have no hair or scalp concerns

Do you wear wigs and head wraps? If yes, how often would you say you wear them? *

n/a if you have no hair and scalp concerns – in your answer please specify wig, head wrap or both

What do you want to gain from this consultation to make your health journey successful? *

be as detailed as you need here

Please share any questions you'd like answered when I return your holistic health action plan? *

At your earliest convenience please send a recent image or video of your hair wet & dry to amena@basiqueopulence.com or 323.334.0406 with your first & last name. Upon receipt I will begin working on your holistic health action plan. On it!

select on it to continue – n/a if you have no hair and scalp concerns – no selection required

Thank you for completing step 1 of your holistic health consultation. You're on your way to the best health of your life! I'll be in touch within 2 business days (Tu-Fri) with next steps.

• looking forward to it!

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