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Address: RR 2 Box 3506  Folkston GA 31537.  

Skin Care Questionnarie Form
First Name:
Last Name:
Email Address:
Age:
Do You Live in the United States?
Which City Do You Live In ?
What State/Country Do You Live In ?
Tell us about your climate. Is it hot, cold, windy, dry, humid, etc.

 

Select the type of skin you believe you have

 
Skin Type:
Very Dry
Dry/Mature
Normal to Dry
Normal
Normal to Oily
Oily
Very Oily
Blemished
Skin Characteristics
Dry all over--all the time, tight, easily irritated
Mostly dry, tight, maturing or sun-damaged, loss of softness/suppleness
Normal to Oily in the T-Zone, Dry on the sides of the face
Slightly Oily in the T-Zone, Normal on the sides of the face
Oily in the T-Zone, Normal to oily on the sides of the face
Very Oily in the T-Zone, slightly oily on the sides of the face
Very Oily all over--all the time, prone to breakouts but not necessarily problem/blemished
Oily all over with frequent problem breakouts
Is your skin sensitive or easily irritated by products?
Do you use a regular skincare routine now?
What brand of products and specifically which products do you use now?

 

Where do you currently purchase your skincare products?

 
Purchase Location
Salon or Spa
Department Store
Drug Store
Direct from a Rep
Don't Use Any Skincare Products
Sample Brands
AFE, Murad, MD Formulations, Dermalogica, Babor, SkinCeuticals, etc.
La Prairie, Estee Lauder, Lancome, Clarins, Erno Laszlo, Clinique, Shiseido, etc.
L'Oreal, Almay, Cetaphil, Oil of Olay, Neutrogena, Clean & Clear, etc.
Mary Kay, Beauticontrol, Avon, Amway, etc.
What type of cleanser do you use now?
Does your face feel tight at times?
Where is your face tight, and when?
How long does your foundation last?
Do you spend time in the sun?
Do you use sunscreen when you'll be in the sun?
Do you use Retin A?
If you use Retin A, what do you use it for?
If you use Retin A, how long have you been using it?
Do you have irritation, sensitivity, flaking from the Retin A?
How many glasses of water do you drink each day?
What is your ethnic background?
How do you view your skin? Tell us about problems, concerns, etc. that affect your skin.
Do You have Facial Lines?
Facial Lines Are
Facial Lines are located
Eye Area (Corners of Eyes, Under eyes)
On the Forehead
From the nose to mouth and on the Face
Around the mouth and lips
On the Throat
What is the overall texture of your face?
Do you have Blackheads?
Does your skin blemish/break out?
If you breakout, where do blemishes occur (check all that apply)?
Forehead
Between Eyebrows
Nose
Sides of Nose
Chin
Cheeks
Sides of Face
Jawline
Describe your skin's firmness
Do you have Dry Patches?
If you have dry patches, where do they occur (check all that apply)?
Forehead
Between Eyebrows
Nose
Sides of Nose
Chin
Cheeks
Sides of Face
Jawline
Describe your Pore Size
What is the length of time until you feel oily after washing?
Do you have Broken Capillaries (Small red broken blood vessels that show through your foundation)?
Which selection best describes your complexion?
Even toned, generally evenly colored
Slightly discolored (ruddy or sallow) but can be easily covered with foundation
Very ruddy and easily irritated
Very sallow
Blotchy and unevenly toned
Dull and lifeless
Other--please describe
Describe your Skin Thickness
Which of the following are of specific concern to you (check all that apply)?
Fine Lines Around the Eyes
Undereye Shadows
Puffy Eyes
Lines on the Throat
Facial Lines/Loss of Firmness
Shiny Areas
Blotchiness
Dry Skin/Dry Patches
Thick or Blemish Prone Skin
Tiny Bumps Under the Skin
Dark Spots/Hyperpigmentation
Rosacea
Dry Lips





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