Your Personalized Skin Care Analysis Form Name * First Name Last Name Email * Phone (###) ### #### Date of Birth MM DD YYYY Occupation SKIN TYPE & CONCERNS How would you describe your skin type? Normal (balanced, not too dry or oily) Dry (tight, rough texture) Oily (shiny, especially in T-zone) Combination ( oily T-zone, normal/dry elsewhere) Sensitive (easily irritated, redness) Which areas of your face tend to get oily? Select all that apply Forehead Nose Chin Cheeks None What are your primary skin concerns? Select up to 3 Fine lines/Wrinkles Acne/Breakouts Blackheads/Clogged pores Dark spots/Hyperpigmentation Redness/Irritation Dryness/Flakiness Dullness/Uneven texture Under-eye concerns (puffiness, dark circles) Loss of Firmness/Elasticity Visible pores Excessive oil production Other Do you experience breakouts? Never Rarely Sometimes Often Very frequently If you experience breakouts, where do they typically occur? Select all that apply Forehead Cheeks Chin Jawline Nose N/A SKINCARE HISTORY Have you ever had professional treatments? Never Rarely (1-2 times per year) Occasionally (3-5 times per year) Regularly (6+ times per year) What professional treatments have you received in the past year? Select all that apply Traditional facial Chemical Peel Microdermabrasion Hydrafacial LED light therapy Microneedling None Other Do you currently use any prescription skincare products? Yes No Have you used any prescription skincare products in the past? Yes No CURRENT SKINCARE ROUTINE Morning Routine Select all that apply Cleanser Toner Serum Eye Cream Moisturizer SPF Other Evening Routine Select all that apply Makeup remover/oil cleanser Cleanser Toner Serum Eye Cream Moisturizer Other How often do you exfoliate? Daily 2-3 times per week Once a week Rarely Never What type of exfoliation do you use? * Physical (scrubs, brushes) Chemical (AHA's, BHA's, enzymes) Both None Do you use SPF (sunscreen) daily? Yes No Only when expecting extended sun exposure List any skincare products you're currently using that you love: List any skincare products you've tried that didn't work for you: LIFESTLYE FACTORS How many glasses of water do you drink daily? 0-2 3-5 6-8 8+ How would you rate your stress level on average Very low Low Moderate High Very high How many hours of sleep do you typically get? Less than 5 5-6 7-8 9+ How often do you exercise? Never 1-2 times per week 3-4 times per week 5+ times per week Do you smoke? Yes No Occasionally Do you consume alcohol? No Occasionally 1-3 drinks per week 4-7 drinks per week 8+ drinks per week How often are you exposed to the sun? Rarely (mostly indoors) Moderate (some outdoor activities) Frequently (outdoor work/activities) Very frequently (outdoors most of the time/outdoor lifestyle) HEALTH FACTORS Do you have any allergies or sensitivities? Yes No Not sure Are you currently pregnant? Yes No Trying to become pregnant NA Are you currently breastfeeding? Yes No NA Do you have any health conditions that might affect your skin? Select all that apply Rosacea Eczema Psoriasis Autoimmune condition Hormonal imbalance Thyroid condition Diabetes Cancer/Chemotherapy/Radiation None Other GOALS & PREFERENCES What are your top skincare goals? Select top 3 Reduce signs of aging Clear acne/breakouts Even skin tone/discoloration Reduce redness Dryness/increase hydration Oiliness/decrease oil production Hyperpigmentation/scarring Dullness/brighten Other How complex of a skincare routine are you willing to follow? Minimal (3 steps) Moderate (4-6 steps) Comprehensive (7+ steps) Consultation goals? What specifically would you like to achieve from this consultation? Is there anything else you would like us to know about your skin or concerns? Virtual consultation consent * I understand this virtual consultation does not replace any medical advice. I consent to discussing my skin concerns and personal information via video conference. I understand product and treatment recommendations will be based on the information I provide. Thank you! Your form has been submitted. Congratulations on taking the first steps to better skin. Looking forward to speaking with you and helping you achieve your goals!
