Skin Analysis Questionnaire

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Skin Care Questionnaire

Please complete the following questionnaire and submit. This document is best completed and viewed from a desktop.

* Indicates required field

Full Name *

Date of Birth *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Referred By *

Phone Number *

Cell/Mobile Phone Number *

May I have permission to add you to our text promotions? *

Your mobile phone may be subject to additional fees.

FREE Skincare Resource Guide, when you subscribe to my monthly newsletter. Would you like to subscribe? *

What conditions would you like to improve about your skin? (Select all that apply) *

Acne Fine Lines/Wrinkles Uneven Tone/Texture Enlarged Pores Age Spots/Freckles Hormonal Pigmentation Dehydration Dark Circles Saggy Skin Oily Skin Blotchiness

Have you tried any treatments to address your concerns? What has worked and what has not? *

Example: I want to improve my acne. I have tried BPO and it worked for a month, then a broke out worse than before the BPO.

When was your last facial? *

List any additional concerns that you would like to improve: *

Occupation *

Work Lifestyle (select all that apply) *

Physical Outdoors Stressful Exposed to Hazardous Environments Exposed to Hazardous Chemicals Sedentary

Do you wear sunscreen when you go to work? *

Do you workout before or after work? *

Cleanser(s)

Do you use one? *

BRAND NAME *

Exfoliation(s)

Do you use one? *

BRAND NAME *

TONER(s)

Do you use one? *

BRAND NAME *

Serum(s)

Do you use one? *

BRAND NAME: *

Moisturizer(s)

Do you use one? *

BRAND NAME: *

Eye Cream/Gel

Do you use one? *

BRAND NAME: *

SPF/Sunscreen(s)

Do you use one? *

BRAND NAME: *

Mask(s)

Do you use one? *

BRAND NAME: *

How would you rate your general health? *

Are you currently taking medications? IF YES, please list: *

If not taking any, please indicate No

Are you currently taking supplements? IF YES, please list: *

If not taking any, please indicate No.

FEMALE ONLY: Are you currently: *

Nursing Pregnant Planning to become pregnant

Have you experienced or currently experiencing any of the following: *

High Blood Pressure Low Blood Pressure Skin Bruising Varicose Veins Rosacea Headaches High Cholesterol Dermatitis Eye Infection Anemia Herpes Simplex Broken Capillaries Keloid Scarring NONE OF THE ABOVE

Please comment on all marked above *

Has a physical prescribed (currently or in the past) any of the following: *

Benzoyl Peroxide Accutane Retin-A Differin Hydrocortisone Triluma Tretinoin Hydroquinone Metrogel Sulfur Topical Steroids Topical Antibiotics NONE OF THE ABOVE

Do you currently smoke? *

Do you have a history of smoking? *

Have you ever had allergic reactions to any of the following (Select all that apply) *

Aspirin Grapes Salicylates Seafood or Iodine Dairy (Milk) Latex or Kiwi Apples Citrus Berries NONE OF THE FOLLOWING

List any known allergies: *

If you have no known allergies, please indicate : NKA

Are you currently under a physical care? *

YES NO

Are you under a physicians care for any of the following conditions: *

Cancer Radiation Therapy Diabetes Eating Disorder Asthma Hepatitis Epilepsy Facial or Oral Surgery Botox/Fillers Lupus Stroke Thyroid Disorder Cardiac Disorder Endometriosis Poly-cystic Ovaries Hysterectomy Osteoporosis Menopause NONE OF THE ABOVE

Please comment on all marked above *

List any major illnesses and/or surgeries: *

What do you do most during your leisure time (select all that apply) *

Outdoors (Sports, Gardening, Hiker) Sedentary Indoor Athlete Workout more than 2x a week Partier or Life of the Party Thrill Seeker Curl Up and Read a Good Book

Do you use sunscreen? *

YES NO SOMETIMES

What level of SPF do you use? *

Do you use a tanning booth? *

Do you prefer easy, simple home care routines? *

Do you sunbathe? *

Do you like complex skin care routines? *

Do you have furry or feathered companions at home? *

Describe your hobbies: *

I understand that some skin conditions may require more than one treatment and home care products to achieve the desired results. Results cannot be guaranteed due to individual skin types and condition as well as compliance. I have acknowledged that all of the information provided by me is true and correct to the best of my knowledge.

The information I have given above is true and correct to the best of my knowledge. *

Please type your full name to confirm.

DATE *

Submit

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Skin Care Questionnaire

​Cleanser(s)

​Exfoliation(s)

​TONER(s)

Serum(s)

Moisturizer(s)

​Eye Cream/Gel

​SPF/Sunscreen(s)

​Mask(s)

​

SERVICES

SUPPORT

Cleanser(s)

Exfoliation(s)

TONER(s)

Eye Cream/Gel

SPF/Sunscreen(s)

Mask(s)