Hair And Skin Questionnaire
Name
First Name
Last Name
What Is Your Age?
0-12
13-19
20-30
30-45
45-55
55+
What Is Your Gender?
Male
Female
Prefer Not To Say
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SKIN
Please Select Your Concerns
Acne
Blemishes
Excess oil
Pigmentaion
No Hydration
How Often Does Your Acne Appear?
About Once A Month
About Once In Three Months
Always Present
Break Out Due To Certain Products
Describe The Fine Lines Around Your Eyes And Forehead
NO FINE LINES
1
2
3
4
DEEP AND PROMINENT FINE LINES
5
1 is NO FINE LINES, 5 is DEEP AND PROMINENT FINE LINES
How Often Do You Apply Sunscreen?
Everyday
Sometimes
Rarely
Do You Have Enlarged Pores?
Normal Size
1
2
3
4
Enlarged Pores
5
1 is Normal Size, 5 is Enlarged Pores
Are You Currently Using Any Prescription?
Yes
No
Don't Know
The Skin On The Forehead & Nose Bridge Feels
Oily
Dry
Normal
The Skin On Your Cheeks Feels
Oily
Dry
Normal
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HAIR
What Is Your Natural Hair Like?
Straight
Wavy
Curly
My Hair Is
Natural
Coloured
Smoothened/Straightened
What Is Your Natural Hair Texture?
Fine
Medium
Thick
How Would You Describe Your Scalp?
Dry
Oily
Sensitive
Healthy
What Is Your Primary Concern?
Hair Fall
Damaged,Brittle Hair
Dandruff
Frizzy
Prone To Oily Hair
Hair Dryness
Lack Of Shine
Lack Of Volume
Scalp Senstivity
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