Free Skin Care Analysis

Use the form below for a FREE personal skin care analysis done by our aestheticians. The results will help you understand exactly what you need to overcome your skin-related problems. You will receive an evaluation and product recommendations specifically designed for you. This is NOT an auto-responding web page but customized skin care products recommended for you by our expert staff. We understand how difficult is it is to choose the right products. This analysis will help you make informed decisions about how to handle your home skin care routine. Please make sure you answer every question on the form so we can provide you a complete evaluation. The information you provided is completely confidential nd used only for analysis.
Name
Address
City
State
Zip
Email
Phone
How did you find our web site?	Search Engine Advertisement Television If other, please enter here:
The Basics	1. Your Age:
	2. Your Sex is: Female Male

Facial Surgery
	3a. Have you had laser resurfacing or facial plastic surgery in the past 3 months? Yes No
	3b. Are you planning to have facial resurfacing soon? Yes No
	3c. Are you planning to have eyelid surgery soon? Yes No
	3d. Are you planning to have other facial plastic surgery soon? Yes No

Lifestyle
	4. Do you smoke? Yes No
	5. Do you have allergies to any of the following? (Check all that apply) Aspirin Talc Clindamycin Retin-A Hydroquinone Alpha Hydroxyacids Beta Hydroxyacids Fragrances Hydrogen Peroxide No allergies to any of the above
	6. Do you currently take any antioxidant supplements? Yes No
	7. Do you use Retin-A? Yes No 7a. If yes, what do you use it for? Acne Fine Lines 8. Do you have irritation, sensitivity, flaking from Retin A use? Yes No
	9. Are you now using the Acne drug Accutane? Yes No 9a. If no, have you used Accutane in the past? Yes No 9b. If you used it in the past, how long ago?
	10. Are you currently on a restricted diet? Yes No
	11. Do you exercise regularly? Yes No
	12. What water temperature do you cleanse with? Cool Warm Hot
	13. Do you have any special skin problems? (Check all that apply) I have adolescent Acne eruptions. I have adult onset Acne. I have deep cystic Acne. I have oily skin, but no eruptions. I have dry skin with Acne outbreaks. I have lines and wrinkles from sun damage (photoaging). I have combination skin, dry in some places, oily in the T zone. I have hyperpigmentation (brown spots from sun or Acne). I have Acne scarring. I have smooth, normal skin. I have enlarged pores. I have no special skin problems.
	14. Are you susceptible to cold sores? Yes No
Your Current Skin Products
	15. What types of cleansers are you now using? Soap Cleanser Lotion Cream 16. Are you currently using bar soap to cleanse your face? Yes No
	17. Do you use any skin care products which contain mineral oil, lanolin, alcohol, color, fragrance, or formaldehyde? Yes No
	18. What type of skin do you have? Dry Normal to Dry Normal Normal to Oily Oily
	19. What product line are you currently using?
	20. Have you used glycolic? Yes No Don't Know 20a. If you have used glycolic, what percentage?
	21. Have you had microdermabrasion in the past? Yes No
	22. Have you had chemical peels in the past? Yes No 22a. If yes, what kind of peels? Glycolic TCA Lactic Jessners Other:
Women Only	If you selected female above, you must answer both of these questions:
	23. Are you taking oral contraception? Yes No
	24. Are you pregnant, trying to become pregnant, or breast feeding? Yes No
Men Only	25. If you selected male above, you must answer both of these questions:
	26. Do you ever experience irritation from shaving? Yes No
	27. Do you experience ingrown hairs? Yes No
Oil Secretion
	28. What time of day do you first notice oil? 15 to 30 minutes after cleansing Midmorning 9am to 10am Lunch time 12pm Midafternoon 2pm to 3pm Late Day 4pm to 5pm Total Dry I do not experience breakthrough oily shine during the day
	29. Do you experience skin break-outs? Yes No
Moisture Hydration
	30. How much plain water do you consume daily? 1-2 cups 3-4 cups 5-6 cups 7+ cups
	31. When you are in the sun for extended periods, do you use a sunscreen/sunblock Yes No
Capillary Activity
	32. Do you have a tendency to redness in skintone? Yes No
Skin Type
	33. Which of the following most closely describes your skin type? Very fair skin tone, blond, or redhead, freckles, burns easily, never tans Light skin tone, will tan, but usually burns Light to olive skin tone, sometimes burns, hazel eyes, auburn to light brown hair Medium brown skin tone, rarely burns Dark brown skin tone, very rarely burns, dark eyes, dark hair Dark skin tone, burn resistant, dark eyes
Skin Quality	Please tell us about the following qualities of your skin:
	34. Facial Lines: a few or none some around the eyes around the eyes and on the face around the lip area
	35. Do you have eye area puffiness? No Occasionally Frequently
	36. Do you have dark undereye shadows? No Occasionally Frequently
	37. Your skin texture is: bumpy and uneven smooth and soft coarse and grainy
	38. Do you have blackheads? few or none some, especially in the T-zone problem
	39. Do you have small, red broken capillaries that show through your foundation? problem (nose/cheeks/chin) few none
	40. Does your skin have dry patches? never occasionally frequently
	41. Is your skin extremely dry? Yes No
	42. Your skin pour size: enlarged all over some enlarged in the T-zone nearly invisible
	43. Your skin thickness: very thick normal very thin
	44. Do you wear glasses? Yes No
	45. Please choose up to three skin care issues that you would like help with. You must select at least one and no more than three. Clear up Acne eruptions Clear up blackheads Minimize size of pores Decrease oiliness of skin Diminish the appearance of capillaries on the face Lighten skin complexion or hyper pigmentation areas Restore skin elasticity Hydrate the skin Smooth skin texture Diminish flakiness of skin Lighten Acne scarring Diminish wrinkles and fine lines Pre-facial surgery skin preparation Post-facial surgery skin care No special results, just a regimen for my skin