Skin Analysis Form
fill in as much or as little as you can
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Consultation Option
Email
Phone
Zoom
Age this is not necessarily how old you are but how aged is YOUR skin?
Please Select
20 - 30
30 - 40
40 - 50
50 - 60
60 - 70
70 - 80
Which skin group do you belong to using the Fitzpatrick scale?
Please Select
1. Always burns very white freckles usually light eyes blond or red hair.
2. Usually burns tans with difficulty white fair skin blur grey green eyes.
3. Average tanning sometimes burns white olive gold tone hazel or brown eyes.
4. Rarely burns brown olive or light brown dark brown hair brown eyes.
5. Very rarely burns brown or dark brown skin dark brown eyes brown / black hair.
Describe your Skin
The skin barrier consists of the skin’s micro biome and its the first area we look at.
How would you describe it?
Thick outer layer?
Yes
No
Thin outer skin?
Yes
No
Reacts easily to anything?
Yes
No
Balanced (the Goal)
Clear
No Pigment
No Blemishes
Oily
Acne
Breakouts
Inflamed
Oily in Certain Areas (combination skin)
Blackheads
Whiteheads
Wrinkled
Fine Lines
Expression Lines
Deep Wrinkles
Dehydrated (lacking moisture)
Dry
Flaky
Tight Feeling
Gets Red Easily
Sensitive
Itchy (including eyelids)
Burns Easily
Blotchy
Fragile
Pigmented (where?)
Pigmented (why?)
Pregnancy
Sun
Malasma
If you have sun damage, how much?
Do you have rosacea?
Yes
No
Do you have excema?
Yes
No
Do you have large pores?
Yes
No
Do you have broken capillaries?
Yes
No
Do you have black heads underneath your skin?
Yes
No
Do you have whiteheads underneath your skin?
Yes
No
Is your skin rough to the touch?
Yes
No
Does anything else stand out in your skin that you would like to share?
Submit
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