Is the
condition of your skin the best that it can be? How
can you make it healthier? What products are best suited
to your skin type? How can you protect your skin from
sun exposure, dryness and premature aging? The Skinterra
skin analysis, free to all visitors, can help you answer
these questions and arrive at a customized daily skin
care routine perfect for you.
Need immediate
advice? Try our interactive
Shopping Assistant.
Instructions: Please
read and answer each question carefully. A listing of
product recommendations and an individualized daily
skin care routine that best addresses your specific
skin care needs will be e-mailed to you within 24 hours.
The information you provide is strictly confidential
and will be used only for the purpose of skin analysis.
PLEASE NOTE: Unless otherwise noted, all questions must
be completed.
Full Name:
E-mail:
Your
Age is:
under 19
19-25
26-35
36-45
46-59
60+
Your
Sex is:
Female
Male
1.
Which of the following most closely describes your skin
tone:
Very Fair, burns easily, never tans, freckles (typically
red hair)
Light, burns first, then tans (typically blond hair)
Light Olive, sometimes burns (typically light to medium
brown hair)
Medium Olive, rarely burns (typically Asian or Hispanic)
Dark Brown, never burns (typically African-American)
2.
Which of the following best describes you skin type:
Very Oily Skin, large pores
Oily Skin
Combination Skin, oily in the T-zone, dry/normal cheeks
Normal Skin
Dry Skin, small pores
3.
Does your skin break out?
Almost Always
Frequently
Rarely
Never
4.
How would you describe your skin?
Sensitive
Resilient
Not Sure
5.
Do you have small, red, broken blood vessels on your
face?
Yes
No
6. Do you spent a lot of time outdoors?
Yes
No
7.
Do you wear sunscreen?
Always
Sometimes
Never
8.
Do you go to tanning booths?
Frequently
Sometimes
Never
9.
Do you have any "age spots" or sun damage
on your face?
Yes
No
10.
Do you smoke?
Yes
No
11.
Are you currently using Retin-A or Renova?
Yes
No
12.
If so, how long have you been using it?
under 3 months
3 months-1 year
1-3 years
over 3 years
13.
Do you experience any irritation, dryness or flakiness
from Retin-A?
Yes
No
14.
Are you currently using the drug Accutane?
Yes
No
15.
Have you undergone laser skin resurfacing in the last
3 months?
Yes
No
16.
Do you have allergies to any of the following?
Alpha-hydroxy acids
Hydroquinone
Preservatives
Fragrances
17.
List any other known allergies: (optional)
18.
Are you pregnant?
Yes
No
N/A
19.
Are you trying to become pregnant?
Yes
No
N/A
20.
Are you taking oral contraceptives?
Yes
No
N/A
21.
Do you use regular skin care routine now?
Yes
No
22.
What type of a cleanser are you using?
soap
gel
lotion
cream
23.
What line(s) of skin care products are you currently
using? (optional)
24.
is there a specific product line(s) that you are interested
in? (optional)
25.
What kind(s) of results are you looking for? (Check
all that apply)
26.
Please list any additional concerns you would like for
us to address:
27.
Please indicate the amount you would like to spend:
(optional)
under $40
$40 - $80
$80 - $120
over $120
28.
Would you like to receive updates on special offers
and promotions?
Yes
No
29.
How did you find out about our website? (optional)
By
submitting this form, I acknowledge that I have read
and understand the following: This skin analysis questionnaire
cannot substitute for the completeness of an in-person
consultation with a trained skin care specialist.
