Skin and Skincare Questionnaire

Photo of the right side

Photo of the left side

Straight on photo

First Name *

Last Name *

Age *

Gender *
 female male

Ethnicity *

Email *

Do you have any skin or food allergies? If yes, please describe.

Check if you are allergic to:
 Sulphur Aspirin Shell Nuts

Please list any topical or internal medications that you are currently using.

Are you presently taking birth control pill?
 Yes No

Are you using any prescription topicals from the dermatologist, i.e. steroids, retinoids, Accutane, Hydroquinone, RetinA, Tazorac, etc.
 Yes No

Do you undergo laser hair reduction, laser skin treatments, electrolysis, or chemical peels?
 Yes No

What are your skin concerns?
 Blackheads Whiteheads Dark spots Age spots Razor bumps Dry, dehydrated skin Flaky skin Sensitive skin Oily skin Fine lines/wrinkles Deep or permanent lines/wrinkles

What is your current AM regimen?

What is your current PM regimen?

Skin Type Information

Choose your T-zone (zone, where your skin is usually oily):

•  nose only (if any at all)
•  from the center of the face to the inner corner of the eye
•  from the center of the face to inner corner of iris
•  from the center of the face to the middle of the eye
•  entire face

 
After cleansing, your skin appears oily
 Never In 10-12 hours In 7-9 hours In 4-6 hours In 1-3 hours

If not moisturized, your skin on the face feels tight:
 Always Sometimes Rarely Never

2-3 hours after applying foundation (no powder), your makeup appears:
 Flaky Smooth Shiny I don’t wear make up

How often does your face get red, especially after moderate exercise, drinking hot or alcoholic beverages, wind, indoor heat, hot or cold weather?
 Never Something Frequently Always

Your face looks red in photos (if you have no makeup):
 Never Something Frequently Always

Have you or someone in your family been diagnosed with atopic dermatitis, eczema or contact dermatitis (an allergic skin rash)
 Yes, sever case Yes No I don’t think so

Skin Pigmentation Information

How many dark spots did you develop when you were pregnant, took birth control pills or hormone replacement therapy.
 None One A few A lot n/a (because I am male, or have never been pregnant or taken birth controls pills or HRT)

Have you ever been diagnosed with melasma, or ‘pregnancy mask’?
 No It went away Yes n/a (because I am male, or have never been pregnant)

When you are exposed to sun, do you develop freckles?
 Never A few A lot

Do you have dark spots or patches on your upper lip or cheeks? Or have you had them in the past that you’ve removed
 No Slightly noticeable Very noticeable