Facial Analysis Form JudgeMD Web

First up, what's your name?* This field is required.

First Name

Last Name

Email* This field is required.

example@example.com

Phone Number* This field is required.

Please enter a valid phone number.

Age* This field is required.

Zip Code* This field is required.

Age

Date

Do you smoke?

No, never

Used to

Yes, socially

Yes, regularly

Have you had any aesthetic procedures? (select all that apply)

Injectables (e.g. Botox or Fillers)

Chemical skin treatments (e.g. peels)

Medical grade skincare

Energy based skin treatments (e.g. laser)

Other minimally invasive (e.g. vampire facial, PRP, hair transplants)

Surgical (e.g. liposuction, facelift)

None: I’m new to medical aesthetics

What would you like to improve?Let's work together to achieve your beauty goals. Let us know what specific improvements you are looking for, whether it's enhancing your natural features or addressing particular concerns.

I want to look good for my age

I want to improve my facial balance

I want to look less tired

I want to look more feminine

I want to look more masculine

I just want to look better

What is your area of interest?* This field is required.

Face

Breast

Abdomen/Back

Labia

Skin

Other

Which regions of the face?* This field is required.

Eyebrows

Eyes

Cheeks

Nose

Lips

Face and neck aging

Ears

Jawline/chin

Other

Which breast complaints?* This field is required.

Too big

Too small

Sagging

Asymmetric

Other

Which abdomen/back complaints?* This field is required.

Loose/excess skin

Excess fat

Bra rolls

Other

Concerns of the labial area* This field is required.

Discomfort in clothing

Excess skin

Aesthetics

Discomfort with activity

Other

Which skin complaints?* This field is required.

Acne

Wrinkles

Pigment

Texture

Sun damage

Thin

Thick

Oily

Dry

Redness

Other

What brought you to JudgeMD's site?

Learn about aesthetic issues

Learn about treatment options

Learn about product recommendations

Recommendation from friend

Learn about this provider

Other

Do you want to book a consultation?

No, I just want my report

Maybe later

Yes, contact me

Tips for best scan resultsTake a selfie from just below your shoulders to just above your head Hold the phone level with your face Look up at the camera

Upload Neutral Expression Selfie* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 1.0GB

Tips for best scan resultsCenter your face, then rotate your chin ALL THE WAY to your left shoulder, then rotate your chin ALL THE WAY to your right shoulder Hold your phone at eye level Light your face evenly, ideally with daylight Video required, make sure to switch your device to the right setting

Upload 180º Video* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 1.0GB

Tips for best scan results3 expressions video 1. Scrunch your eyebrows 2. Raise your eyebrows 3. Give us a big cheesy smile

Upload Facial Expression Video* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 1.0GB

Which skin goal is most important to you?No pressure, you can tell us more in a sec!

Clear acne

Treat rosacea

Fight wrinkles

Other

And what other goals can we help with?Choose as many as you’d like—our personalized formulas are made to multitask.

What's your skin type? This helps your provider pick the right ingredients—at the right strengths—for your skin.

How sensitive is your skin?Let us know if your skin is easily irritated when using new products.

My skin is easily irritated

My skin is rarely irritated

I don't typically try new products

How would you describe your acne?Select the description that most closely matches your skin.

What products do you use?Understanding your routine helps us make personalized recommendations for your skin. (Select all that apply)

Cleanser

Moisturizer

Lip balm

Sunscreen

Makeup

None of the above

What is your gender identity?We want to take your life circumstances and experiences into account when determining your treatment. We understand that gender identity can differ from sex, and we support all identities!

Cisgender man

Cisgender woman

Transgender man

Transgender woman

Gender nonbinary

Other

What is your assigned sex at birth?We ask so that we can provide safe and relevant medical care. Hormones play a big role behind the scenes of your skin!

Male

Female

What race(s) do you identify with?Select all that apply.

White

Hispanic or Latinx

Black or African American

Central or East Asian

South or Southeast Asian

Middle Eastern, North African or Arab

Native American

Native Hawaiian or Other Pacific Islander

Other race or origin

Prefer not to say

Have you ever used retinol?Knowing your experience with this ingredient helps us personalize your formula.

YESNO

How did your skin respond to retinol?

My skin responded well

My skin got irritated

Have you ever used any prescription topicals (creams, gels, etc.) for acne, skin aging, dark spots, or rosacea?

YESNO

Which prescription topicals have you used?(Select all that apply)

Retin-A / Retin-A Micro (tretinoin)

Tazorac / Avage (tazarotene)

Ziana / Veltin (tretinoin and clindamycin)

Adapalene / Differin

Epiduo (adapalene and benzoyl peroxide)

Duac / Benzaclin / Acanya

Ivermectin

Metronidazole

Azelaic Acid

None of the above

Have you taken (or are you currently taking) any prescription pills for acne or rosacea?

YESNO

Which prescription pills have you taken for acne or rosacea?(Select all that apply)

Doxycycline / Oracea / Doryx

Minocycline / Solodyn / Minocin

Spironolactone / Aldactone

Accutane / Isotretinoin / Claravis

Ivermectin

None of the above

DoxycyclineAre you currently taking Doxycycline?

YESNO

DoxycyclinePill dosage and frequency (e.g., 50mg once daily)?

DoxycyclineLength of use (e.g., 6 months).

DoxycyclineDoes or did it help your skin?

DoxycyclinePlease describe any side effects you experienced.

DoxycyclineWould you like to continue (or restart) taking it?

Do you have any allergies?We’d like to know about allergies to medications, product ingredients, etc.

Yes, I have allergies

No, I don't have allergies

What are you allergic to and what is your reaction?Be as specific as possible. Heads up: Your custom formula is created for you and takes your allergies into account — but our other products do not. Please read the full ingredient list before trying our cleanser, moisturizer, body wash, and other products.

[For Dr. J - PRE-VISIT] Skin Diagnostic (from PerfectCorp)

Spots

Wrinkles

Moisture

Redness

Oiliness

Acne

Texture

Dark Circles

Eyebag

Skin Firmness

Droopy Under Eyelid

Droopy Lower Eyelid

Radiance

Visible Pores

Skin Type

[For Dr. J - PRE-VISIT] Complementary Discussion

Skincare

Chemical Peels

Neurotoxins

Filler

Surgical facial rejuvenation

Lasers

Fat reduction

Skin Tightening

Threadlift

[For Dr. J - PRE-VISIT] Complementary Products

Cleanser/Face Wash

Toner

Sunscreen

Serums

Retinol/Tretinoin

Eye Product(s)

Exfoliants

Moisturizer

Vitamin C

Lip Product(s)

Other

[For Dr. J - PRE-VISIT] Complementary Surgical Intervention

Rhinoplasty

Facial Fat Grafting

Dimpleplasty

Neck/Chin Lipo

PDO Thread Lift

Blepharoplasty

Facelift / Necklift

Brow Lift / Forehead Lift

Earlobe Repair / Ear Reshaping

Otoplasty

Chin Aug

Buccal Fat Pad Removal

[For Dr. J - DURING/POST-VISIT] Did you/patient bring up recommendations?

YESNO

[For Dr. J - DURING/POST-VISIT] How interested was patient in follow-ups?

1 (Least interested)

6 (Most interested)

[For Dr. J - DURING/POST-VISIT] What timeline is patient interested?

Next week

Next month

Next few months

Next year

Next few years

Unclear/not interested

[For Dr. J - DURING/POST-VISIT] How effective was this approach?

1 (Least effective)

6 (Most effective)

[For Dr. J - DURING/POST-VISIT] How interested

[For Dr. J - DURING/POST-VISIT] Notes