Please enter the required information.

Full Name:    E-mail: Invalid E-mail Address.

Your Age is:     Please enter the required information.

under 19     19-25      26-35     36-45     46-59     60+

Your Sex is:    Please enter the required information.

Female        Male

1. Which of the following most closely describes your skin tone:   Please enter the required information.

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 your skin type:   Please enter the required information.

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?   Please enter the required information.

Almost Always     Frequently     Rarely     Never

4. How would you describe your skin?   Please enter the required information.

Sensitive     Resilient     Not Sure

5. Do you have small, red, broken blood vessels on your face?    Please enter the required information.

Yes     No

6. Do you spend a lot of time outdoors?    Please enter the required information.

Yes     No

7. Do you wear sunscreen?   Please enter the required information.

Always     Sometimes     Never

8. Do you go to tanning booths?   Please enter the required information.

Frequently     Sometimes     Never

9. Do you have any "age spots" or sun damage on your face?   Please enter the required information.

Yes    No

10. Do you smoke?    Please enter the required information.

Yes     No

11. Are you currently using Retin-A or Renova?    Please enter the required information.

Yes     No

12. If so, how long have you been using it?   Please enter the required information.

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?    Please enter the required information.

Yes     No

14. Are you currently using the drug Accutane?    Please enter the required information.

Yes     No

15. Have you undergone laser skin resurfacing in the last 3 months?   Please enter the required information.

Yes     No

16. Do you have allergies to any of the following?   Please enter the required information.

Alpha-hydroxy acids Hydroquinone Preservatives Fragrances

17. List any other known allergies: (optional)

18. Are you pregnant?   Please enter the required information.

Yes     No     N/A   

19. Are you trying to become pregnant?    Please enter the required information.

Yes     No     N/A  

20. Are you taking oral contraceptives?    Please enter the required information.

Yes     No     N/A  

21. Do you have a regular skin care routine now?   Please enter the required information.

Yes     No

22. What type of a cleanser are you using?   Please enter the required information.

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?   Please enter the required information.

Yes     No

29. How did you find out about our website? (optional)

Image Verification:	Refresh Image
	Please enter the required information.Incorrect Entry Enter the characters you see above.
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.