SKIN CARE ANALYSIS

Any effective skin care program must be individualized to your skin type. Age, sun exposure, hormones, medications and medical problems can all affect your skin type and suggest a change in your skin care program. To be sure you’re choosing the right products for your skin, complete the following questionnaire.

Select the answer that best applies to your skin. Please choose one answer only.

Name:
E-mail:

GENERAL

What is your age?

How would you characterize your skin color?

How would you characterize your eye color?

What is your natural hair color?

MOISTURE BALANCE

How do you characterize your skin?

After normal washing how do you characterize your skin?

How would you describe your face midday?

Does your skin have blemishes or blackheads?

SENSITIVITY

How does your skin respond to skin care products?

Does your skin respond with blemishes from products?

How does your skin respond to the sun?

How does your skin react when you use a facial toner?

PIGMENTATION

Does sun exposure produce freckles or brown spots?

How many freckles or brown spots are on your face?

How many freckles or brown spots are on unexposed skin areas?

Do you have small blood vessels on your face?

TEXTURE

How would you describe your skin's firmness?

Do you have wrinkles on the forehead, around the eyes, between the eyebrows, cheeks, around the lips, or at the corner of the mouth?

How would you describe your pore size?

What is the overall texture of your skin?