Skin Assessment

Date* This field is required.

Date

Name* This field is required.

First Name

Last Name

Date of Birth* This field is required.

Heritage/Ethnicity* This field is required.

E-mail* This field is required.

example@example.com

What is your skin type?* This field is required.

Dry (no visible pores - think the skin of an apple)

Combo/Dry

Oily (visible pores - think the skin of an orange)

Combo/Oily

Sensitive

Which of the below best describes your skin when exposed to the sun?

Always burns easily, never tans

Always burns, tans slightly

Burns moderately, tans gradually

Seldom burns, always tans

Rarely burns, deep tan

Never burns

Does your skin easily get red/flushed and/or feel hot to the touch ?* This field is required.

Yes, my skin can stay red for long periods of time and/or is rosacea-prone

Yes, my skin gets red after a shower, physical activity, or using certain products but doesn't stay that way for long

No, this is generally not an issue for me

Would you consider your skin easily reactive?* This field is required.

Yes - I consider my skin delicate and reactive

Yes - But only if I use products that are too strong for my skin

No - Not generally

How often do you exfoliate?* This field is required.

What is 'exfoliate?'

1x/week

3x/week

Everyday

Describe your current evening routine. Please be specific when listing products (include brand & product type/name)* This field is required.

Describe your current morning routine. Please be specific when listing products (include brand & product type/name).* This field is required.

What skin challenges (we all have them) would you like to address? Select all that apply* This field is required.

Improved skin tone

Smooth fine lines

Reduce under eye circles/puffiness

Smooth texture

Calm redness/reduce sensitivity

Increase hydration/moisture

Minimize breakouts

Balance oil

Overall luminosity

I just need an AM & PM routine

Please list all known allergies* This field is required.

Please list ALL prescribed, over the counter, including vitamins, and recreational drugs (past & present)* This field is required.

Are you taking birth control? * This field is required.

Yes

Are you pregnant or trying to become pregnant?* This field is required.

Yes

Recently had a baby and am breastfeeding

PROFESSIONAL SKIN CARE & SERVICES

Have you ever received chemical peels, laser services, or microdermabrasion treatments? * This field is required.

Yes, within the last month

Yes, within the last 2-3 months

Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?* This field is required.

Yes, currently using

Yes, but not within the last 30 days

Yes, but not within the last 6 months

Not sure

Have you received any of the following in the past 30 days?* This field is required.

Botox

Fillers

Laser Treatment

Other*

N/A

If you selected 'other,' describe here.

HABITS & LIFESTYLE

Do you smoke?* This field is required.

Yes

Do you drink more than 4 caffeinated beverages/day? (tea/coffee, soda, energy drinks)* This field is required.

Yes

How often do you exercise?* This field is required.

Daily

5-6 x/week

3-4 x/week

1-2 x/week

Less than 1-2 x/week

Please rate your stress level* This field is required.

Low

Medium

High

How much water do you drink per day?* This field is required.

0-1 glass

2-4 glasses

5-7 glasses

8 or more

Do you drink alcohol?* This field is required.

Never

1-2 x/week

3-4 x/week

Daily

MOMENT OF TRUTH

How much time are you interested in spending on your skin care routine?* This field is required.

Basic - I prefer using only a few products

Essential - I am open to using a few other key products

Complete - I prefer using a comprehensive routine for maximum results

SELFIE TIME

For best results, please take the photos without any makeup in natural light.

Selfie #1: Straight-on, facing the camera

Selfie #2: Right side facial profile

Selfie #3: Left side facial profile

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

FINAL THOUGHTS

Your job is done. We'll take it from here!

Your esthetician will review in preparation for your virtual skin health consultation.

If acne is your primary concern, you may want to check out the Acne Clearing program for much more in-depth coaching.