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?