Skincare Assessment
Name
First Name
Last Name
Email
example@example.com
Age
<20
20-45
45-60
60-80
>80
Ethnicity
NZ European
Māori
Pacific Peoples
Asian
Middle Eastern/Latin American/African (MELAA)
Prefer not to say
Other
Skin Type
How would you describe your skin (select all appropriate boxes)
Dry
Oily
Sensitive
Ageing
Fine lines and wrinkes
Deep set lines and wrinkles
Redness
Pigmentation
Acne
Dark circles under eyes
Thin, crepey skin under the eyes
Current Skincare Regimen
Morning
Evening
Relevant Medical History
Do you have any medical conditions that affect what skincare products you use?
Yes
No
Additional information
Message for Dr Anne
Signature
Date
-
Day
-
Month
Year
Date
Continue
Continue
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