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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?
*
YES
NO
Option 3
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?
*
Yes
No Thank you
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?
*
Yes
No
Do you workout before or after work?
*
YES, Before work
YES, After work
YES, during my lunch or break
YES, sometimes before and sometimes after
NO
Cleanser(s)
Do you use one?
*
YES
NO
BRAND NAME
*
Exfoliation(s)
Do you use one?
*
YES
NO
BRAND NAME
*
TONER(s)
Do you use one?
*
YES
NO
BRAND NAME
*
Serum(s)
Do you use one?
*
YES
NO
BRAND NAME:
*
Moisturizer(s)
Do you use one?
*
YES
NO
BRAND NAME:
*
Eye Cream/Gel
Do you use one?
*
YES
NO
BRAND NAME:
*
SPF/Sunscreen(s)
Do you use one?
*
YES
NO
BRAND NAME:
*
Mask(s)
Do you use one?
*
YES
NO
BRAND NAME:
*
How would you rate your general health?
*
Excellent
Good
Fair
Poor
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?
*
YES
NO
Do you have a history of smoking?
*
YES
NO
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?
*
YES
NO
Do you prefer easy, simple home care routines?
*
YES
NO
SOMETIMES
WORK DAYS/WEEKDAYS
Do you sunbathe?
*
YES
NO
Do you like complex skin care routines?
*
YES
NO
ONLY ON THE WEEKENDS
SOMETIMES
Do you have furry or feathered companions at home?
*
YES
NO
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
Home
JOIN MY NEWSLETTER
COVID-19 SAFETY
What's New...
HUSH & HUSH
SERVICES
MINI SERVICES
PLATINUM SKIN CARE SERVICES
eGIFT CARDS
VIRTUAL CONSULT
Wedding Season Treatments
SHOP
SKIN NUTRITION
MASKNE SUPPORTS
eGIFT CARDS
ALL PRODUCTS
>
CLEANSERS
MOISTURIZERS
EYE CREAMS
SERUMS
SUNSCREENS
MASKS
>
HYDRATING MASKS
Exfoliating Masks
Apothecary and Metaphysical Collection
DIY FACIALS
FACIAL DEVICES
RECOMMENDATIONS
HOW TO...
Anti-Aging
>
Anti-Aging PART 2
ACNE
>
Comedogenic Ingredients
Lifestyle Choices
Makeup Brushes
Laundry
Swimmers
QUARANTINE
>
FOOD PLACES
FOR FIRST RESPONDERS
RECIPES
>
Turmeric Froth - The anti-inflammatory flush
Blueberry Chia Seed Protein Breakfast
Contact
CONTACT FORM
Skin Wellness Coaching
Corporate Rewards
First Time Clients
Skin Analysis Questionnaire
Join a Zoom Party
>
Zoom Facial Party Questionnaire
PRIVATE ZOOM PARTY
Blog
Anti-Aging Arsenals
Sunscreens
Support Small Businesses
Virtual Consultations