Skin and Skincare Questionnaire

Photo of the right side

Photo of the left side

Straight on photo

First Name *

Last Name *

Age *

Gender *
femalemale

Ethnicity *

Email *

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

Check if you are allergic to:
SulphurAspirinShellNuts

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

Are you presently taking birth control pill?
YesNo

Are you using any prescription topicals from the dermatologist, i.e. steroids, retinoids, Accutane, Hydroquinone, RetinA, Tazorac, etc.
YesNo

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

What are your skin concerns?
BlackheadsWhiteheadsDark spotsAge spotsRazor bumpsDry, dehydrated skinFlaky skinSensitive skinOily skinFine lines/wrinklesDeep 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
NeverIn 10-12 hoursIn 7-9 hoursIn 4-6 hoursIn 1-3 hours

If not moisturized, your skin on the face feels tight:
AlwaysSometimesRarelyNever

2-3 hours after applying foundation (no powder), your makeup appears:
FlakySmoothShinyI 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?
NeverSomethingFrequentlyAlways

Your face looks red in photos (if you have no makeup):
NeverSomethingFrequentlyAlways

Have you or someone in your family been diagnosed with atopic dermatitis, eczema or contact dermatitis (an allergic skin rash)
Yes, sever caseYesNoI 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.
NoneOneA fewA lotn/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’?
NoIt went awayYesn/a (because I am male, or have never been pregnant)

When you are exposed to sun, do you develop freckles?
NeverA fewA 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
NoSlightly noticeableVery noticeable