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Age: |
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What City Do You Live In? |
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What State Do You Live In (If US)? |
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What Country Do You Live In? |
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Tell us about your climate. Is it hot, cold, windy, dry, humid, etc. |
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Select the type of skin you believe you have |
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Is your skin sensitive or easily irritated by products? |
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Do you use a regular skincare routine now? |
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What brand of products and specifically which products do you use now? |
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What type of cleanser do you use now? |
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What type of skin are your skincare products designed for? |
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Does your face feel tight at times? |
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Where is your face tight, and when? |
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How long does your foundation last? |
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Do you spend time in the sun? |
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How many hours are spent in the sun each week (average)? |
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Do you use sunscreen when you'll be in the sun? |
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Do you use Retin A? |
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| If you use Retin A, what do you use it for? | |||||||||||||||||||
| If you use Retin A, how long have you been using it? | |||||||||||||||||||
| Do you have irritation, sensitivity, flaking from the Retin A? | |||||||||||||||||||
How many glasses of water do you drink each day? |
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What is your ethnic background? |
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How do you view your skin? Tell us about problems, concerns, etc. that affect your skin. |
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Do You have Facial Lines? |
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Facial Lines Are |
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What is the overall texture of your face? |
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Do you have Blackheads? |
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Does your skin blemish/break out? |
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If you breakout, where do blemishes occur (check all that apply)? |
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Facial Lines are located |
Eye Area (Corners of Eyes, Under eyes) On the Forehead From the nose to mouth and on the Face Around the mouth and lips On the Throat
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Describe your skin's firmness |
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Do you have Dry Patches? |
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If you have dry patches, where do they occur (check all that apply)? |
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Describe your Pore Size |
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What is the length of time until you feel oily after washing? |
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Do you have Broken Capillaries (Small red broken blood vessels that show through your foundation)? |
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Which selection best describes your complexion? |
Even toned, generally evenly colored Slightly discolored (ruddy or sallow) but can be easily covered with foundation Very ruddy and easily irritated Very sallow Blotchy and unevenly toned Dull and lifeless Other--please describe
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Describe your Skin Thickness |
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