Skin Care Questionnaire By completing this profile you will be helping us to correctly evaluate your needs. All information will be kept in strict confidence. First Name (required): Last Name (required): Your Email (required): Phone Number (I may have specific questions regarding your skin): Area code: Phone number: Gender ---FemaleMale Please list any allergies Age (assists in diagnosis) Medications/Vitamins taken currently or in the last 90 days. Please check any health problems you have had or are currently experiencing. High/Low Blood pressureAsthmaHeart ConditionsAre you pregnantAre you trying to conceive?Hormone disordersHysterectomyDiabetesHypoglycemiaCancerSkin Cancer Please give details of any of the above conditions. Have you ever undergone treatment from a dermatologist ---YesNo If so, please give details Have you ever experienced an allergic reaction to a skincare product? If so please give details What skincare brand do you currently use? Which of the following product do you currently use? CleanserToner/LotionDay moisturiserNight moisturiserEye creamSunscreenExfoliantMaskSerums/Booster products Describe your skin type SensitiveNormalDry (younger skin)Dry (mature skin)OilyTends to breakoutMature (fine lines, loss of elasticity) Do you tan easily? ---YesNo Do you have any current skin problems? ---YesNo If you could change, or improve something about your skin , what would it be? Use this form for a FREE personal skin care analysis done by our estheticians. The results will help you understand exactly what you need to overcome your skin-related problems. You will receive an evaluation and recommendations specifically designed for you. This is NOT an auto-responding web page, but customized skin care and skin care products recommended for you by our expert skin care therapist staff. Each analysis requires at least 10 to 20 minutes of study time prior to recommending the skin care products prescription. We understand how difficult it is to choose the right products. The skin care analysis will help you make informed decisions about how to handle your home skin care. Please make sure that you give as many answers to the questions on the form, all answers are required so that we can perform a complete evaluation of your skin.