Your Age is:
Your Sex is:
1. Which of the following most closely describes your skin tone:
Very Fair, burns easily, never tans, freckles (typically red hair)
Light, burns first, then tans (typically blond hair)
Light Olive, sometimes burns (typically light to medium brown hair)
Medium Olive, rarely burns (typically Asian or Hispanic)
Dark Brown, never burns (typically African-American)
2. Which of the following best describes your skin type?
Very Oily Skin, large pores
Combination Skin, oily in the T-zone, dry/normal cheeks
Dry Skin, small pores
3. Does your skin break out?
4. How would you describe your skin?
5. Do you have small, red, broken blood vessels on your face?
6. Do you spend a lot of time outdoors?
7. Do you wear sunscreen?
8. Do you have any "age spots" or sun damage on your face?
9. Do you smoke?
10. Are you currently using the drug Accutane?
11. Have you undergone laser skin resurfacing in the last 3 months?
12. Do you have allergies to any of the following?
13. List any other known allergies: (optional)
14. Do you have a regular skin care routine now?
15. What type of a cleanser are you using?
What line(s) of skin care products are you currently using? (optional)
17. What kind(s) of results are you looking for? (Check all that apply)
Diminish fine lines and wrinkles
Improve texture of the skin
Even out skin tone
Clear up acne breakouts
Lessen number of blackheads
Lighten "age" spots
Minimize size of pores