Skin Care Assessment

Skin Care Assessment
Answer the following questions to the best of your ability. This will help evaluate your skin type & assess any additional skin care needs. From here we can build your custom skincare plan!
Date:

MonthDayYear
Date
First & Last Name:
Email Address:
Mobile #:
Skin Type
1. How would you describe the level of oil on your skin?

A. No oilinessB. No oil in T zone, light in other areasC. Oily, mostly in T zoneD. Oily all over
2. How would you describe how your skin feels?

A. Tight and itchyB. Healthy for the most part, occasionally tight or flakyC. Healthy for the most part, occasionally oily
3. How would you describe the overall appearance of your skin?

A. Tight, noticeable fine lines, red or rough patches, and visible flakingB. Healthy appearance, clear with even texture, some tightness or flakingC. Healthy appearance, occasional breakouts, can appear shiny
4. How would you describe the size of your pores?

A. SmallB. Small to MediumC. Medium to Large
Skin Care Solutions
What, if any, challenges do you have with your skin?
How often do you experience blemishes?

DailyWeeklySeveral times a monthN/A
By midday, does you skin look/feel...

Flaky/ItchyTight/DryRed/BlotchyOily/ShinyOther
Do you have any known skin disorders? If so please specify.
Do you have any allergies?
How much water do you consume daily?
How much caffeine do you consume daily?
How much time do you spend in the sun?
How often do you shave? (Male Specific)
Should be Empty: