Skin and Skincare Questionnaire

This questionnaire of your skin enables us to evaluate your skin type and condition correctly.

To analyze your specific situation and create the perfect strategy for your skin, we need four digital photos of your skin.

You can take the pictures with your smart phone. There are simple rules to follow:

  • Do not use flash.
  • Make sure that your pictures are not fuzzy or blurry.


 female male

Check if you are allergic to:
 Sulphur Aspirin Shell Nuts

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.

Do you undergo laser hair reduction, laser skin treatments, electrolysis, or chemical peels?

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

Skin Type Information

  • face1 nose only (if any at all)
  • face2 from the center of the face to the inner corner of the eye
  • face3 from the center of the face to inner corner of iris
  • face4 from the center of the face to the middle of the eye
  • face5 entire face

 Never In 10-12 hours In 7-9 hours In 4-6 hours In 1-3 hours

 Always Sometimes Rarely Never

 Flaky Smooth Shiny I don’t wear make up

 Never Something Frequently Always

 Never Something Frequently Always

 Yes, sever case Yes No I don’t think so

Skin Pigmentation Information

 None One A few A lot n/a (because I am male, or have never been pregnant or taken birth controls pills or HRT)

 No It went away Yes n/a (because I am male, or have never been pregnant)

 Never A few A lot

 No Slightly noticeable Very noticeable