Name *

First Name

Last Name

Facial Appearance Satisfaction *

My photos after completing my sessions compared to my photos prior to starting my program appear:

Younger

Older

No change

Satisfaction with appearance of facial skin (complexion):

Improvement in tone:

Not Satisfied

Satisfied

Improvement in radiance:

Not Satisfied

Satisfied

Improvement in smoothness:

Not Satisfied

Satisfied

Improvement in Firmness

Not Satisfied

Satisfied

Forehead and Eyebrow Satisfaction

Forehead looks youthful and smooth:

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Forehead lines are less:

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Forehead lines are not as deep:

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Lines between eyebrows appear improved when relaxed:

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Improved appearance of position and height of eyebrows:

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Eyes

Satisfaction with appearance of eyes:

Eyes appear youthful, attractive and open:

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Upper eyelids no longer appear droopy, saggy, heavy or make me look tired or old:

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Area under the eyes no longer have bags and wrinkled skin, or make me look tired or old :

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Appearance of crow’s feet are no longer visible when not smiling or squinting:

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Cheeks

Satisfaction with appearance of cheeks:

Appearance of cheeks are full and no longer have wrinkles:

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Appearance of cheekbones have improved in shape, contour and symmetry, as well as how attractive, high and well-defined the cheekbones look.

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Nasolabial folds

Satisfaction with appearance of nasolabial folds:

Appearance of nasolabial fold lines are no longer seen when relaxed:

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Lips

Satisfaction with appearance of lips:

Lips are appropriate size, shape and fullness for my face when smiling:

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Appearance of lines around the lips are less and not as deep:

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Mouth

Satisfaction with marionette lines:

The marionette lines (lines that run downward from the corner of the lips to your chin that make me look old, tired, angry or sad have improved:

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Chin/Jaw

Satisfaction with lower face and jawline

The appearance of the jawline looks prominent and sculpted:

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

The appearance of the area under the chin no longer has loose and sagging skin and as can be seen in profile:

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Neck

Satisfaction with appearance of neck:

Improvement in wrinkles, hanging and sagging skin on the neck and as can be seen in profile:

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Overall *

Satisfaction with the decision to complete a face exercise program (worth the time, effort and cost):

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Satisfaction with the outcome:

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Perceived age versus chronological age shows a difference of greater than 10 years:

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I feel good about the age my face looks when looking in the mirror and photos:

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

I am happy and confident with the appearance of my face after my completing my private coaching session:

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree