Questionnaire (online but private):
Name:
Address:
Email:
Phone:
Gender:
- Female
- Male
What is your age Category?
- Under 18
- 19-29
- 30-39
- 40-49
- 50-59
- 60+
What is your Skin Color?
- Very fair/Porcelain
- Fair
- Medium/Olive
- Dark
- Very dark
How is your environment?
- Harsh
- Dry
- Humid
- High Altitude
- Normal
How many hours of sleep?
How diligently do you use SPF?
How frequently do you travel?
What type of skin care routine are you looking for?
- Intro Kits (I prefer only a few products)
- Advanced Kits (I prefer a fairly simple routine)
- Ultimate Kits (I prefer a routine to address my concerns)
- Complete Kits (I prefer a comprehensive routine for max results)
What best describes your skin type?
- My skin is oily all over or in mid face
- My skin is sensitive, red, and oily
- My skin gets oily in t-zone and can get dry
- My skin is sensitive, dehydrated, but prone to a few breakouts
- My skin is neither real oily or real dry
- My skin is mostly dry
- My skin is very dry
- My skin is sensitive, prone to redness, and dry
How is your Skin Clarity?
- Normal
- Blackheads
- Breakout prone
- Whiteheads
- Acne
How is your Skin Tone?
- Normal
- Freckles
- Uneven
- Sun Damage
- Melasma
- PIH (post-inflammatory hyperpigmentation)
- Post Acne red scars
How is your Skin Texture?
- Smooth
- Rough
- Large Pores
- Uneven/ Not Smooth
- Light Scars
- Deep Scars
How is your Skin Aging?
- Normal Aging
- Few fine lines in an area
- Volume loss under eyes, mid face, nasolabial folds
- Fine lines and elasticity depleted slightly
- Lack of elasticity and volume depleted slightly
- Advanced Wrinkles, elasticity, volume
How is your Skin Sensitivity?
- Dehydrated (tight feeling after cleansing)
- Sensitive (mostly to harsh products or extreme weather)
- Sensitive (in general)
- Not Sensitive
- Redness (easily red or splotchy)
- Reactive (easily irritated or intolerant of most products)
- Rosacea (Redness, inflammation, dilated capillaries, possible flushing/pimples)
Do you use Retinoids, Acids or Peels? Yes / No
Any allergies to:
- Aspirin
- Benzoyl Peroxide
- Hydroquinone
- Retinoids
Do you prefer a matte finish, or more emollient moisturizer for a dewy finish?
- Matte
- Dewy
- Matte for day, heavier at night
What is your number 1 concern?
- General Aging
- Pigmentation
- Lack of Elasticity / Sagging
- Brown Spots
- Loss of Volume
- Fine Lines
- Wrinkles
- Broken Capillaries
- Large pores
- Oily
- Dehydration
- Blackheads / Whiteheads
- Irregular texture
- Eyes
- Aging
- Scarring
- Redness
- Eczema/Psoriasis
What is your number 2 concern?
- General Aging
- Pigmentation
- Lack of Elasticity / Sagging
- Brown Spots
- Loss of Volume
- Fine Lines
- Wrinkles
- Broken Capillaries
- Large pores
- Oily
- Dehydration
- Blackheads / Whiteheads
- Irregular texture
- Eyes
- Aging
- Scarring
- Redness
- Eczema/Psoriasis
What is your number 3 concern?
- General Aging
- Pigmentation
- Lack of Elasticity / Sagging
- Brown Spots
- Loss of Volume
- Fine Lines
- Wrinkles
- Broken Capillaries
- Large pores
- Oily
- Dehydration
- Blackheads / Whiteheads
- Irregular texture
- Eyes
- Aging
- Scarring
- Redness
- Eczema/Psoriasis
Anything else you would like us to know?