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Skin Care Questionnaire

Free Skin Care Analysis Questionnaire



First Name: *
Last Name: *
Address:
City:
State:
Country:
Zip:
Email: *
Any known allergies:
Birth date (mm/dd/yr):
1. What is your specific Concerns with you skin:
(Please answer each of the following)
a. Dehydration (dry skin): Yes No
b. Whiteheads: Yes No
c. Blackheads: Yes No
d. Excess Oil: Yes No
e. Milia: Yes No
f. Pigmentation: Yes No
g. Acne: Yes No
h. Sensitivities: Yes No
i. Visible capillaries: Yes No
j. Signs of aging: Yes No
k. Active Lesions: Yes No
# of lesions
2. What products do you currently use (include brand) of Skincare, Cosmetics, Shampoo/Conditioner:
3. How often do you cleanse your face:
4. Have you ever had an allergic reaction to products you have applied to your skin: Yes No
4a. What products did you react to:
5. Are you using glycolic acid products: Yes No
5a. If so glycolic acid %:
6. Have you ever had professional glylolic acid treatment: Yes No
6A. (if so, how often):
7. Have you ever had a chemical peel: Yes No
7a. (if so, how often):
8. Please list all medications you take or any topical treatments you use:
9. Is your diet balanced:
10. Do you smoke: Yes No
11. Do you have a physically active lifestyle:
12. What are your sleeping habits:
13. How much water do you drink every day:
14. How many caffinated beverages do you drink everyday (including chocolate, ice tea, tea):
15. How much sun exposure do you get in an average week:
15a. Time of day are you in the sun:
16. Do you use sunscreen: Yes No
16a. SPF Number:
17. Your age is:
18. Any additional comments or concerns:


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