Skincare Questionnaire
Please fill out this form to receive your personalized product selection!
Date
*
-
Month
-
Day
Year
Date Picker Icon
Name
*
First Name
Last Name
Mobile Number
*
-
Area Code
Phone Number
E-mail
*
example@example.com
Your Skin
What are your skin care goals?
*
Acne Free
Wrinkle Free
Brighter
Younger Looking
What is your skin type?
Dry
Oily
Combination
Sensitive (I get an allergic reaction to certain ingredients--not pimples)
Acne-Prone
Normal (balanced)
What are your skin care challenges?
*
Wrinkles / Fine Lines
Hyperpigmentation / Sun Damage
Acne / Acne Scarring
Redness / Rosacea
Dullness
Aging
Large pores
Melasma
Sensitivity
Other
Please feel free to go into more detail
What Skin Care Products do you currently use?
*
Cleanser / Face Wash
Bar Soap
Face Scrub / Exfoliants
Toner
Serums
Moisturizer
Sunscreen
Eye Product(s)
Lip Product(s)
Please list your products here. Specificity is key! I need to know the name, strength, brand, etc.
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differin, Retinol, or other Vitamin A derivitives?
*
Yes, currently using
Yes, but not within the last 30 days
Yes, but not within the last 6 months
No
Not sure
Do you prefer any of the following:
Fragrance-free
Vegan/cruelty free
Organic/natural
Clinical/medical grade
Not sure/No preference
What is your product budget preference?
Drugstore ($-$$)
Mid range $$-$$$
Luxury-Medical $$$
No budget or not sure
Do you wear daily SPF on its own, not in a makeup product?
Yes
No
Do you wear makeup often/daily?
Yes
No
How many steps/products are you comfortable with AM and PM?
Any known allergies?
*
Aspirin
Tree Nuts
Latex
Dairy
Fruits
Vegetables
Shellfish
Iodine
Fragrances / Essential Oils
Other
None
If Other, please specify
Have you used or been prescribed any medications (topical or oral) for acne / acne control?
*
Yes
No
If yes, please specify what and date last used
Are you a smoker?
*
Yes
No
Social
Please rate your stress level
*
Low
Medium
High
Are you pregnant or trying to become pregnant?
*
Yes
No
Recently had a baby and am breastfeeding
N/A
Are you undergoing any hormone replacement therapy?
Yes
No
If yes, please specify
Anything else I need to know before I customize your regimen?
My Products
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Personalized Skincare Regimen
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