Skincare Questionnaire
Please fill in all information as accurately as possible to get the best results. If you have questions contact us at 618.408.2077
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Select your skin type below. If you are unsure, please choose the one that sounds most similar to you.
*
I - White; very fair: red or blond hair; blue eyes; freckles. Always burns, never tans.
II - White; fair; red or blond hair; blue, hazel, or green eyes. Usually burns, tans with difficulty.
III - Medium white to olive; fair; with any eye or hair color; very common. Sometimes mild burn; gradually tans.
IV - Olive, Moderate Brown; typical Mediterranean Caucasian skin. Rarely burns, tans with ease.
V - Dark Brown; mid-eastern skin types. Very rarely burns, tans very easily.
VI - Black. Never Burns, Tans very easily.
Are you currently pregnant, actively trying to become pregnant, or nursing?
*
Yes
No
The following information is essential to optimize your treatment plan.
How would you describe your skin? (select all that apply):
*
Dry
Combination
Oily
Acne-Prone
Sensitive
Please select your concerns from the following list (select all that apply):*(required)
*
Fine Lines
Rosacea
Sun Damage/Dark Spots
Pores
Dryness
Texture
Acne
What skin care products do you currently use? (Select all that apply)
*
Cleanser
Eye Cream
Moisturizer
Sunscreen
Toner
Exfoliant
Serum
Other
Please select any prescription medications you are currently taking (select all that apply):*(required)
*
Accutane
Retin A
Tazorac
Differen
Renova
Antibiotics
None
Other
Are you allergic to any cosmetic ingredients, medication or food?
*
Yes
No
If so, which ingredients, medications, or food:
In a few words, please describe your primary concerns or goals for your skin.
*
Please provide at least one recent picture of your skin.
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