www.kirschderm.com - Skincare Quiz

1

Which of the following best describes your age?

18 to 25 years

25 to 40 years

40 to 60 years

60+ years

2

How often do you get pimples and pustules on your face?

All the time

Some of the time

Rarely

Never

3

Answer for Quiz 1

4

How would you describe the overall pigmentation/color of your facial skin?

Lots of Discoloration

A Few Dark Spots

No Dark Spots

5

Are you interested in a prescription treatment?

Yes

No

6

Answer for Quiz 3

7

Do you have areas of discoloration and dark spots you would like to treat in areas other than your face?

Yes

No

8

Answer for Quiz 11

9

How would you describe the overall sensitivity of your facial skin?

Very sensitive

Moderately sensitive

Mildly sensitive

Not sensitive

10

Answer for Quiz 4

11

What bests describes the texture of your skin feel if you gently run your finger across your forehead, down your cheek and across your chin?

Smooth, Soft and Supple

Rough & Patchy

Bumpy & Uneven

12

Answer for Quiz 5

13

Are you interested in longer eyelashes and thicker eye brows?

Yes

No

14

Answer for Quiz 6

15

Are you interested in treatment for hair loss?

Yes

No

16

Answer for Quiz 7

17

What best describes the skin under your eyes?

Dark circles

Swollen

Fine Lines and Wrinkles

No Issues

18

Answer for Quiz 8

19

Do you wear makeup?

Yes

No

20

Answer for Quiz 9

21

Do you wear sunscreen daily?

Yes

No

22

Answer for Quiz 10