WITH SKIN Online Skin Quiz Form

By submitting information on this form you agree to the terms and privacy policy of your Skin Care Specialist.*

I consent to my specialist collecting the submitted data within this form. By completing and submitting data I consent to my specialist contacting me to discuss the information provided.
Full Name*

First NameLast Name
Email Address*
example@example.com
Phone Number (optional)

Country Dialling CodePhone Number
How often do you consume caffeine?*

0 - 2 cups daily2 - 5 cups daily
How would like your specialist to contact you?*

Voice CallEmailother
Please select your age category*

18 - 2425 - 3435 - 4445 - 5455 - 6465 - 7475 - 8485 +
Skin Care products currently used*

CleanserTonerMaskMoisturiserSerumSPFFoundationExfoliator (physical, scrub)Exfoliator (chemical, AHA/BHA)Eye CareRetinol/RetinA
Describe your current routine and products used.
Please send your completed form to info@withskin.com.au
Your skin concerns, please select however many options are relevant to your skin condition.*

Enlarged poresOilinessDryness, flakinessIrritationSensitivity to many productsSensitivity to temperaturesRedness, inflammationBroken capillariesAcneCongestionBlackheadsDark eye circlesHyperpigmentation, dark patchesHypopigmentation, white patchesScarringCystsWrinklesPremature ageingExpression linesSun damageUneven Skin ToneDullnessSkin rashItchingLack of elasticity
If pigmentation is a skin concern, please select the relevant options

pigmentation issues are hormone relatedpigmentation issues are due to sun damagepigmentation issues are geneticpigmentation issues are due to medication or a conditionpigmentation issues occurred following a skin injurypigmentation issues occurred following a medication or conditionI don't know the causes of my pigmentation issues
Select your phototype?*

Type 1, I have fair skin, fair eyes & hair. I never tan when exposed to UV and always burn. I have freckles. Nicole Kidman, Emma Stone could be my twinType 2, I have fair skin. I occasionally tan but burn very easily. I may have freckles on exposed areas to UV Jennifer Anniston and Drew Barrymore could be my twinType 3, I have fair to medium skin, I will burn but tan moderately - Demi MooreType 4, I have medium skin, I rarely burn and tan easily- Jessica Alba, Eva MendezType 5, I have medium to darker skin, I rarely burn and tan extremely easily. My skin appears darker even without UV exposure beyonce , Mindy Kalling could be my twinType 6, I have dark skin, I rarely/never burn. My skin appears dark even without UV exposure, UV exposure does not change my skin colour Michelle Obama, Naomi Campbell
Do you suffer from any skin conditions?*

YesNo
Please list any skin conditions
Upload image front facing here. please note that image should be taken in good lighting, without make up or products. (optional)

Browse Files

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Upload image left profile here. please note that image should be taken in good lighting, without make up or products. (optional)

Browse Files

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Upload image right profile here. please note that image should be taken in good lighting, without make up or products. (optional)

Browse Files

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How does your skin feel/look after cleansing? (you can select more than one option)*

Tight, uncomfortableShows rednessItchyOily in areasNormalOily and shiny all over
How would you describe your skin type?*

Dry, dehydratedOilyNormalCombination
Are you currently taking any medications or supplements?*

YesNo
Please list any medications or supplements
Are you suffering from any medical condition?*

YesNo
Please list any conditions
Are you currently pregnant or breastfeeding?*

YesNo
Do you suffer from allergies?*

YesNot sureNo
Please list any relevant allergies
How would you describe your current stress levels?*

Very high, I feel very stressedHigh, but manageableModerate, very manageableLow, I don't feel stressed at all
How many hours sleep do you get on average a night*

less than 48 hours +4 - 8
How would you describe your diet?*

Poor, high in sugar, processed foods and saturated fatsModerate, I consume generally a good diet but occasionally eat foods high in sugar, processed or saturated fats. My diet could be betterMy diet is healthy, I eat a varied diet including fresh produceI have a restricted diet through choiceI have a restricted diet through intolerances & health reasons
How much water do you drink daily?*

0 - 5 glasses5 + glasses
Do you excercise regularly?*

YesNo
Please add any further information you feel is relevant to your diet & lifestyle
Do you use or do you have history of cigarette smoking?*

YesNo
Do you tan or use artificial tanning beds?*

YesNo
How often do you consume alcohol?*

DailyWeeklyMonthlyOccasionallyNever
How often do you consume caffeine?*

DailyWeeklyMonthlyOccasionallyNever
You can leave a message for your specialist here;
Disclaimer
Nothing on this site is intended to establish a physician-patient relationship, to replace the services of a trained physician or otherwise to be a substitute for professional medical advice, diagnosis, or treatment.

The questionnaire serves to provide us prior to a consultation with information that can be used to create a guideline of skin care products and correct aesthetic treatments based upon the answers provided by you.

Any remote consultation is not intended to replace a hands on consultation by a Skin Care Professional and we recommend for the best results that you go for a complete skin care analysis With skin analysis imaging.
Click submit and we will contact you to arrange your consultation.
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