Fill-out a Skin Care Questionnaire

Fill-out a Skin Care Questionnaire

Skin Care Education
Tips for revealing a fresh new face; Melanie Vasseur

First Name: *
Last Name: *
Address:
City:
State:
Country:
Zip:
Email: *
Any known allergies:
Birth date (mm/dd/yr):
Register for free drawing Type in Register:	and you can stop here. Scroll to bottom and submit form.
1. What specifically concerns you about your skin:
a. Dehydration (dry skin):	Yes No
b. Whiteheads:	Yes No
c. Blackheads:	Yes No
d. Excess Oil:	Yes No
e. Milia:	Yes No
f. Pigmentation:	Yes No
g. Acne:	Yes No
h. Sensitivities:	Yes No
i. Visible capillaries:	Yes No
j. Signs of aging:	Yes No
k. Active Lesions:	Yes No # of lesions
2. What products do you currently use (include brand) of Skincare, Cosmetics, Shampoo/Conditioner:

3. How often do you cleanse your face:
4. Have you ever had an allergic reaction to products you have applied to your skin:	Yes No
4a. What products did you react to:

5. Are you using glycolic acid products:	Yes No
5a. If so glycolic acid %:
6. Have you ever had professional glylolic acid treatment: 6a. (if so, how often):	Yes No

7. Have you ever had a chemical peel: 7a. (if so, how often):	Yes No

8. Please list all medications you take or any topical treatments you use:

9. Is your diet balanced:
10. Do you smoke:	Yes No
11. Do you have a physically active lifestyle:
12. What are your sleeping habits:
13. How much water do you drink every day:
14. How many caffinated beverages do you drink everyday (including chocolate, ice tea, tea):
15. How much sun exposure do you get in an average week:
15a. Time of day are you in the sun:
16. Do you use sunscreen: 16a. SPF Number:	Yes No

17. Your age is:
18. Additional comments or concerns:
Enter the text in the box:
Please take a moment and check all fields before submitting form. Press submit button only once as it may take a moment to go thru. Thank you!

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Fill-out a Skin Care Questionnaire