Beauty & Wellness Evaluation

Wellness evaluation for Tiffany Andersen VIP members and IBTV participants; initiates 21 Day Reset.

Instructions – Step 1
Thank you so much for taking the time to answer the following questions thoughtfully, truthfully and to the best of your ability. We also ask that you provide a photo of your clean, unmade-up face so we can better gauge any potential concerns. This information will provide us insight to prepare sound nutritional advice for you. Thank you for participating in the challenge. We look forward to supporting your success. Once you’ve completed all the questions, click SUBMIT and we will get back to you within 72 hours. Live in good health with beautiful skin!
Today's Date*
DD slash MM slash YYYY
Personal Information
Email
Name
First Last
Date of birth*
Age*
Weight & Measurements
Weight*
Today One year ago Five years ago

please list weight as shown
Measurements
Waist Hips Chest

Please measure your waist, hips and chest
Photo*
Max. file size: 32 MB.

Please provide a photo of your clean face,
HIPAA*
I understand the information I provide below is true and correct to the best of my ability. I also understand that all information stated is strictly confidential and will not be shared outside of this facility as per HIPAA guidelines. I hereby give Renew Medical Spa permission to keep my information on file in compliance with HIPAA regulations.
Phone*
Preferred contact method
- Phone
- Text
- Email
Consent*
I have read and agree to the Wellness Consultation Waiver
I am of sound mind, and in good faith understand that I am completing this form to be used for skincare and nutritional evaluation and advice by Tiffany Andersen, a licensed medical aesthetician and certified holistic health practitioner, and Tony Andersen, PhD and holistic health practitioner.

I understand neither are licensed allopathic medical doctors, and they are not offering me any kind of medical options. They offer sound advice pertaining to whole foods and whole food supplements. They have informed me that they are offering me wellness, nutrition and skincare advice, and I am not being prescribed any drugs, surgery or any other allopathic interventions. I have selected this service by my free and informed choice, as is my right. I am responsible for the outcome of any advice I follow that is given to me and hold harmless Tiffany Andersen, Tony Andersen, Renew Medical Spa, Tiffany Andersen Brands and/or Interactive Beauty TV from any adverse reactions that may occur as a result of changing my diet or taking whole food supplements and herbs. I am fully aware of Tiffany Andersen’s and Tony Andersen’s qualifications and certifications as shown above. I understand they will not discourage me from any protocols medical doctors may have prescribed. I acknowledge that Tiffany Andersen, Tony Andersen and their associates recommend I see or speak with my medical doctor before changing my diet and/or beginning any supplements, especially if I am on medications. I am simply seeking wellness enhancing suggestions that could improve my wellbeing and future wellness from the inside out.

I understand that supplements will be recommended in the final report and I am free to purchase those supplements through the Holistic Journey program or purchase them from any source I wish to use. I further acknowledge that I have paid for this evaluation, I am providing this information of my own free will, and any subsequent information or conversations are solely on my own behalf and not as an agent or informant for any federal, state, local, private or other agency on a mission or entrapment investigation or for any other reason that might bring legal charges against Tiffany Andersen Brands, Tiffany Andersen, Tony Andersen, Renew Medical Spa, Interactive Beauty TV, and/or any affiliates including but not limited to Gavée Gold LLC, Salts Alive LLC, Whole Hope Foundation LLC.
Beauty Assessment ~ Phase 1
Your Skin
Do you consider your skin to be:*
- Normal
- Oily
- Dry
- Combination
Select the most applicable one.
Do you struggle most with:*
- Dehydration
- Aging
- Sensitive Skin
- Acne
Select the most applicable one.
What are your greatest concerns?*
- Wrinkles
- Pigmentation
- Acne
- Rosacea
Select all that apply
Genetic Disposition
Wellness History
Family History
- Cancer
- Diabetes
- Heart Disease
- Mental Illness (Alzheimer’s, depression, dementia, etc.)
- None of these apply
select all that apply for your family.
Are you a smoker?*
Medications*
Please list all medications you are currently taking (including aspirin, antacids, etc.) Please indicate whether they are over the counter (OTC) or prescription, and include dosage and frequency.
Herbs & Vitamins*
Please list any herbs or vitamins you are currently taking, along with the brand name.
Allergies*
Please describe food, medication and environmental allergies.
Are you currently under the care of a physician?*
For what?*
list any conditions/symptoms for which you are under a doctor’s care.
Have you taken antibiotics in the past two years?
Are you pregnant?
Have you been treated for the following?*
- Skin disease
- Acne
- Cold sores
- High blood pressure
- Diabetes
- Cancer
- Hormone therapy
- Strep throat virus
- Headaches
- Allergies
- Sinus
- Congestion
- Asthma
- Depression
- Anxiety
- Irritable Bowel Syndrome
- Constipation
- Hemorrhoids
- Chronic nasal congestion
- None of these apply
select all that apply
Daily stress level*
please select one
How much water do you drink each day?*
please show in ounces
How often do you exercise?*
please describe frequency of exercise
Do you have breast implants*
Do you have any metal implants in your body?*
Where?*
please provide location of metal implants in body
What are your major health concerns?*
When was your last physical exam?*
Occupation
Living situation*
- Alone
- With friends
- Partner/spouse
- Parents
- Children
- Pets
please select all that apply
Dietary information*
- I need a lot of help with my diet
- I eat organic fruits and vegetables daily
- I eat well most days
- I drink water with all meals
- I drink water between meals
- I do not drink 32oz of water or more daily
- I drink tap water
- I drink filtered water
- I drink spring water
- I eat once a day
- I eat 2-3 times a day
- I snack between meals
- I use artificial sweeteners the pink and blue packets
- I eat only organic free range meat (eggs, red meat, chicken}
- I do not care if my meat is organic or free range
- I have gluten sensitivities
- I don’t know if I am gluten sensitive
- I drink alcohol daily
- I drink alcohol 1-2x a week or more
- I rarely drink alcohol
- I don’t drink alcohol at all
- I tend to eat sandwiches or bread daily
- I frequently eat soups and salads
- I am vegan
- I am not vegan
please select all that apply.
Lifestyle habits*
- I engage in physical activity once a week
- I engage in physical activity 2-3 times a week
- I prefer yoga and pilates over weight training in the gym
- I prefer to work out at the gym
- I like classes at the gym
- I would rather do activities outside than anything else (hiking, biking, walking…)
- I consider myself to be a beginner in working out
- I consider myself to be intermediate for working out
- I consider myself to be advanced in working out
- I love to meditate
- I get 8 hours or more of sleep regularly
- I get less than 8 hours of sleep
- I am a morning person
- I am a night owl
- I often wake up in the middle of the night
- I have a hard time falling asleep
- I sleep well during the night
- I feel well rested in the morning
- I wake up in pain in the morning (stiff joints etc.)
- I never work out
- I have no desire to work out
- I want to work out but have no time
- I want to work out but no energy
select all that apply
Emotional & Spiritual Wellbeing*
- I am often not able to express my emotions
- I am dissatisfied with my job
- I am often stressed out and not able to cope properly
- I often feel anxious and nervous for no reason
- I often experience nightmares
- There are many things I would like to change in my life I just don’t know how
- I often feel exhausted
- I don’t enjoy my work
- I find my loved ones easily get on my nerves
- I have very few hobbies
- I am often depressed
- I often become angry with people and feel guilty later
- I have a hard time letting go of the past
- I don’t look towards the future with much enthusiasm
- I can’t concentrate for for extended periods of time
- My outlook is more negative than positive
- I worry about what people think of me
- I tend to see the good in people
- I have a great sense of humor and love to joke around
- I receive great joy from my family
- I have a positive outlook on life
- My job uses all my greatest talents
- I have plenty of energy to do all I want
- I can concentrate on the task at hand for as long as it takes
- I have a strong spiritual faith
- I am able to express anger constructively
- I practice meditation or other relaxation techniques
- I try to maintain peace and tranquility
- I have many close friends I can count on
- I accept full responsibility for my actions
- I trust my intuition and believe that things happen for a reason
- I do not harbor any resentment from the past
- I can feel completely fulfilled even if I am alone
- I have many hobbies and interests to keep me occupied
- How I see myself is more important than how others see me
- I frequently go out of my way to help others
select all that apply
Optimum Nutrition Questionnaire
Symptom Analysis – Vitamins (Sections 1 – 12)
Vitamin Profile Section 1*
- *Mouth ulcers
- Poor night vision
- Acne
- *Frequent colds or infections
- Dry, flaky skin
- Dandruff
- Thrush or cystitis
- Diarrhea
- None of these apply
Mark any symptoms you experience.
Vitamin Profile Section 2*
- Arthritis or osteoporosis
- Bachache
- Tooth decay
- Hair loss
- *Muscle twitching or spasms
- *Joint pain or stiffness
- Weak bones
- None of these apply
Mark any symptoms you experience.
Vitamin Profile Section 3*
- Lack of sex drive
- *Exhaustion after light exercise
- *Easy bruising
- Slow wound healing
- Varicose veins
- Poor skin elasticity
- Loss of muscle tone
- Infertility
- None of these apply
Mark any symptoms you experience.
Vitamin Profile Section 4*
- *Bloodshot, burning or gritty eyes
- *Sensitivity to bright lights
- Sore tongue
- Cataracts
- Dull or oily hair
- Eczema or dermatitis
- Split nails
- Cracked lips
- None of these apply
Mark any symptoms you experience.
Vitamin Profile Section 5*
- *Frequent colds
- Lack of energy
- *Frequent infections
- Bleeding or tender gums
- Easy bruising
- Nose bleeds
- Slow wound healing
- Red pimples on skin
- Acne
- None of these apply
Mark any symptoms you experience.
Vitamin Profile Section 6*
- Lack of energy
- Diarrhea
- Insomnia
- Headaches or migraines
- Poor memory
- Anxiety or tension
- Depression
- Irritability
- None of these apply
Mark any symptoms you experience.
Vitamin Profile Section 7*
- Tender muscles
- Eye pain
- Irritability
- Poor concentration
- “Prickly” legs
- Poor memory
- Stomach pains
- Constipation
- Tingling hands
- Rapid heartbeat
- None of these apply
Mark any symptoms you experience.
Vitamin Profile Section 8*
- Muscle tremors, cramps or spasms
- Apathy
- Poor concentration
- *Burning feet or tender hands
- Nausea or vomiting
- Lack of energy
- Exhaustion after light exercise
- Anxiety or tension
- Teeth grinding
- None of these apply
Mark any symptoms you experience.
Vitamin Profile Section 9*
- *Infrequent dream recall
- *Water retention
- Tingling hands
- Depression or nervousness
- Irritability
- Muscle tremors, cramps or spasms
- *Lack of energy
- None of these apply
Mark any symptoms you experience.
Vitamin Profile Section 10*
- Eczema
- Cracked lips
- Prematurely graying hair
- Anxiety or tension
- Poor memory
- *Lack of energy
- Depression
- Poor appetite
- Stomach pains
- None of these apply
Mark any symptoms you experience.
Vitamin Profile Section 11*
- Poor hair condition
- Eczema or dermatitis
- Mouth sensitive to heat or cold
- Irritability
- *Lack of energy
- Constipation
- Tender or sore muscles
- Pale skin
- None of these apply
Mark any symptoms you experience.
Vitamin Profile Section 12*
- *Dermatitis or dry skin
- *Poor hair condition
- *Prematurely graying hair
- *Tender or sore muscles
- *Poor appetite or nausea
- None of these apply
Mark any symptoms you experience.
Symptom Analysis – Minerals (Sections 13 – 19)
Mineral Profile Section 13*
- *Muscle cramps, tremors, spasms
- *Insomnia or nervousness
- *Joint pain or arthritis
- *Tooth decay
- *High blood pressure
- None of these apply
Mark any symptoms you experience.
Mineral Profile Section 14*
- *Pale skin
- *Sore tongue
- *Fatigue or listlessness
- *Loss of appetite or nausea
- *Heavy periods or blood loss
- None of these apply
Mark any symptoms you experience.
Mineral Profile Section 15*
- *Muscle cramps, tremors, spasms
- Muscle weakness
- Insomnia, nervousness, or hyperactivity
- High blood pressure
- Irregular or rapid heartbeat
- Constipation
- Fits or convulsions
- Breast tenderness, water retention
- Depression or confusion
- None of these apply
Mark any symptoms you experience.
Mineral Profile Section 16*
- *Muscle twitches
- *Childhood “growing pains”
- *Dizziness, poor sense of balance
- *Fits or convulsions
- *Sore knees
- None of these apply
Mark any symptoms you experience.
Mineral Profile Section 17*
- *Decline in sense of taste or smell
- *White marks on fingernails
- *Frequent infections
- *Stretch marks
- *Acne or greasy skin
- None of these apply
Mark any symptoms you experience.
Mineral Profile Section 18*
- *Family history of cancer
- *Signs of premature aging
- *Cataracts
- *High blood pressure
- None of these apply
Mark any symptoms you experience.
Mineral Profile Section 19*
- *Excessive or cold sweats
- *Dizziness, irritability after six hours without food
- *Need for frequently meals
- *Cold hands
- *Need for excessive sleep or drowsiness during the day
- None of these apply
Mark any symptoms you experience.
Mineral Profile – Section 20*
- *Dry skin or eczema
- Inflammatory health problems, such as arthritis
- Excessive thirst or sweating
- Frequent infections
- Poor memory or learning difficulties
- Dry hair or dandruff
- PMS or breast pain
- Water retention
- High blood pressure or blood lipids
- None of these apply
Mark any symptoms you experience.
Take the Toxic Test
If you answer yes to more than ten of these questions, you are likely carrying around TOXINS that are depleting your vital energy sources and creating havoc in your body. Please check all that apply.
Toxic Test*
- Do you brush your teeth daily?
- Do you have metal fillings in your mouth?
- Have you had a root canal?
- Do you shower with unfiltered water in your home?
- Do you drink organic coffee?
- Do you live near industrial places like airports?
- Do you use Windex or other commercial household cleansers?
- Do you work under fluorescent lights?
- Do you use a computer?
- Do you talk on the cell phone for more than ten minutes a day?
- Do you wear your cell phone on your body with a belt holder?
- Do you eat fish that is not wild caught?
- Do you live in a major metropolitan area?
- Do you occasionally get pain or discomfort on your right side after eating?
- Do you drink milk?
- Do you drink soda?
- Do you use perfume?
- Do you color your hair?
- Do you polish your nails?
- Do you have breast implants?
- Do you get Botox or fillers?
- Do you drink alcohol on a regular basis?
- Do you swim in a pool that has chlorine?
- Are you overweight?
- Do you use bug spray in your home?
- Do you eat out more than twice weekly?
- Do you dry clean your clothes?
- Do you take medications?
- Do you have body strong odor?
- Do you struggle with bad breath?
- Do you get sick often?
- Do you feel tired often?
- Do you have trouble sleeping?
- Do you have dark circles under the eyes?
- Do you have skin conditions such as eczema?
- Do you feel stressed or anxious?
- Are you frequently constipated?
- Do you have chronic allergies?
- Do you get headaches often?
- Do you feel depressed often?
- Do you crave sugar?
- None of these apply
select all that apply
Additional Information
Please provide any additional information which would allow us to better assist you.
Reality Health Check
- ARE YOU OFTEN TIRED, STRUGGLE WITH INFECTIONS OR HEADACHES? 75%
- DO YOU SUFFER IN PAIN AND REQUIRE ANTIBIOTICS OR PAINKILLERS? 60%
- DO YOU SUFFER WITH CONSTANT ALLERGIES, JOINT PAIN, INFLAMMATION, OR HAVE TOXIC OVERLOAD? 50%
- DO YOU INTAKE IBUPROFEN, ANTI-INFLAMMATORY DRUGS/PAINKILLERS, OR ANTIBIOTICS REGULARLY? 45%
- DO YOU HAVE CANCER, DIABETES, HEART DISEASE, ARTHRITIS, ALZHEIMER’S OR PARKINSON’S DISEASE? 25%
- ARE YOU DEPENDENT ON CHEMOTHERAPY, BLOOD-PRESSURE PILLS, ANTI-INFLAMMATORIES, OR PHARMACEUTICAL DRUGS OF ANY KIND? DEAD ZONE
Move up with your health
It’s time to get serious about your health! You can change your life! Don’t wait… Start now… Start today!
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Today	One year ago	Five years ago

Waist	Hips	Chest

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Beauty & Wellness Evaluation

Instructions – Step 1

Personal Information

Weight & Measurements

Beauty Assessment ~ Phase 1

Your Skin

Genetic Disposition

Wellness History

Optimum Nutrition Questionnaire

Symptom Analysis – Vitamins (Sections 1 – 12)

Symptom Analysis – Minerals (Sections 13 – 19)

Take the Toxic Test

Move up with your health

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