Laevo Assessment

1
Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.Please entre your birthdate.
Birthdate
Year
Month
Day
3
Email* This field is required.
example@example.com
4
How would you describe your skin right now?* This field is required.
I want to maintain and prevent
I want to correct and stabilize
5
Compared to a few years ago, your skin now feels:* This field is required.
More stable
Slightly more sensitive
More reactive
Harder to manage
Same
Not sure
6
How quickly does your skin recover after irritation or breakouts?* This field is required.
Very fast
Few days
Over a week
Leaves marks
Not sure
7
When your skin gets a mark (acne, irritation), it:* This field is required.
Fades quickly
Lingers for weeks
Turns into dark spots
Keeps coming back
Not sure
8
Does your skin tolerate products the same way it used to?* This field is required.
Yes
Slightly less
No, I react more easily now
Not sure
9
Do you experience:* This field is required.Select all that apply.
Tightness after washing
Burning with products
Flaking / dryness
Oily even after washing
None
10
Your breakouts are:* This field is required.
Rare
Occasional
Hormonal (jawline / monthly)
Frequent / persistent
11
Type of acne:* This field is required.Select all that apply.
Whiteheads / blackheads
Red inflamed pimples
Deep painful cysts
None
12
After breakouts, your skin:* This field is required.
Clears fully
Leaves marks
Leaves dark spots
Leaves both marks and texture
13
Have you noticed any of the following?* This field is required.Select all that apply.
Skin feels thinner (peri/post-menopausal)
Skin looks dull more often
Texture feels uneven
Fine lines appearing
Dark spots (scattered dark brown/grey/black spots)
Dark brown/grey/black patches (around cheeks, chin, mouth and/or forehead areas)
14
Have you used retinoids before?* This field is required.
Never
Yes, tolerated well
Yes, caused irritation
Could not tolerate
15
Which best describes you?* This field is required.
Under 30
30–40
40–50
50+
16
Are you:* This field is required.
Pregnant
Breastfeeding
Trying to conceive
None
17
Do you have:* This field is required.Select all that apply.
Eczema
Rosacea
Psoriasis
None
18
How would your skin react to sun exposure?* This field is required.
Always burns, never tans
Burns easily, tans minimally
Sometimes burns, tans gradually
Rarely burns, tans easily
Very rarely burns, deeply pigmented
19
Do you have any known allergies to medications or skincare ingredients?* This field is required.Please list them all.
20
List your current skincare products.* This field is required.Please be as thorough as possible.
Huge
Large
Normal
Small
Ok
Ok
21
What matters most to you?* This field is required.
My skin feels stable and predictable
I want fewer breakouts
I want even tone
I want overall skin improvement
I want to correct my pigmentation/melasma spots
22
Take a close-up photo of concern area* This field is required.
23
How did you first hear about Laevo? * This field is required.
Please Select
Google Search
ChatGPT or AI Search Tool
Instagram
Facebook
TikTok
Pinterest
YouTube
Friend or Family Recommendation
Healthcare Professional Referral
Pharmacist Referral
Dermatologist Referral
Med Spa or Aesthetic Clinic Referral
Online Article or Blog
News or Media Feature
Existing Earthy Apothecary Customer
Returning Laévo Customer
Other (please specify)
24
Please tell us more (optional)Examples: Who referred you? Which social media account did you see? What were you searching for?
25
Consent* This field is required.
26
Terms and Conditions* This field is required.
Should be Empty: