Skin Questionnaire Name* First Last Telephone*Email* Profession*What are your concerns?FACE. Check all that apply.* Wrinkles & fine lines Acne Redness Sensitivity Excessive shine/Oily skin Skin discomfort (dehydration) Pigmentation spots Comedones Dull skin tone Ingrown hair Loss of skin firmness Other EYES AND LIPS. Check all that apply.* Chapped lips LInes around the lips Loss of firmness Loss of firmness eye area Wrinkles & fine lines Sensitivity Dark circles Puffy eyelids Other What is your homecare regimen?FACE. Check all that apply.* Milk cleanser Gel cleanser Soap cleanser Lotion Exfoliant Mask Concentrate Day cream Night cream Sun protection Other EYES AND LIPS. Check all that apply.* Milk cleanser Gel cleanser Soap cleanser Eye concentrate Eye cream Lip treatment Lip cream Other Are you using medically prescribed skin care?*YesNoAre you presently taking medication?*YesNoList any medications currently taking.*Are you presently under the care of a doctor and/or dermatologist?*YesNoAre you taking Accutane?*YesNoAre you taking Retin A?*YesNoHave you undergone radiotherapy or chemotherapy?*YesNoHave you undergone any of the following treatments? Check all that apply.* Laser Medical dermabrasion Epidermabrasion Chemical Peeling None of the above Dermal Filler Injections Neuromodulators Do you wear a protective mask?*YesNoIf so, how many hours a day?Do you have any of the following? Check all that apply. Heart-pacemaker Thyroid problems Hormonal imbalances HIgh or low blood pressure Herpes Rosacea H.I.V. Hepatitis B Hepatitis C Eczema Psoriasis Allergies Other None of the above List any other current skin conditions or treatments.Select your free one on one skin consultation preference* FREE 30 minute Zoom Virtual consultation FREE 30 minute Telephone consultation FREE 30 minute onsite consultation Please let us know when you prefer to be contacted (day and time).*Privacy Statement:Please rest assured any personal information collected is private and will not be shared with any other parties.NameThis field is for validation purposes and should be left unchanged.
