Skincare Questionnaire

The purpose of this questionnaire is to provide us with a complete overview of your skin. In reviewing your questionnaire we will be able to note any unusual problems, allergic conditions, use of medicaitons, or contributing stress factors. This will help us in the ultimate customization of your personal skin care regimen.

Instructions:
Please read and answer each of the following questions carefully. We will respond to you within 24 hours with a recommended list of products and a daily regimen that will best address your specific skin care needs. We value your privacy. Any information that you provide us is strictly confidential.

Attention: Please use your valid email address. This form will send the results of the processing to the email address you enter below.

Full Name:
Email Address:
Phone:
Age Range:	under 18 19 - 28 29 - 35 36 - 50 51 - 65 65+
Your sex is:	female male
Choose the description that most closely matches your skin type.
	normal dry combination oily skin very oily/problem
How frequently does you skin breakout?
	almost always frequently rarely never
Describe your skin (check all that apply)
	thick thin saggy firm acne cysts rosacea eczema sun-damaged uneven/blotchy mature wrinkled hypo-pigmented (white spots) hyper-pigmented (brown spots) psoriasis broken surface capillaries
Choose the description that most closely matches your skin's reaction to the sun.
	Very white or freckled, always burns in sun, never tans (usually red hair) White, usually burns before tanning (usually blond hair) White to Olive, sometimes burns (light to medium brown hair) Medium Olive , rarely burns (Asian or Hispanic) Dark Brown, very rarely burns (African American) Black, never burns (African American)
Do you consider your skin
sensitive resilient not sure
What is your hereditary background?
Are you pregnant or trying to become pregnant?
	yes no
Are you in the habit of going to tannng booths?
	yes no
Do you currently get facial waxing/electrolysis or use depilatories?
	yes no
Are you currently using Retin-A/Renova/Differin?
	yes no
Are you currently using Accutane?
	yes no
Do you participate in vigorous aerobic activity or sports?
	yes no
Have you recently had facial surgery?
	yes no
Have you recently had laser resurfacing?
	yes no
Are you allergic or sensitive to any of the following?
	milk apples citrus grapes aloe vera aspirin perfumes hyroquinone yes no
Any other allergies? If so, what?
	yes no
Do you smoke?
	yes no
Do you spend a lot of time outdoors?
	yes no
Do you wear sunscreen?
	always sometimes never
Are you using glycolic/AHA home care products?
	yes no
How does your skin react to them?
Have you ever used any products that caused a bad reaction?
	yes no If so what were they
What products are you currently using?
What kind of results are you looking for?