Stephs A1 Beauty Bar Skin Assessment

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Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Do you prefer to receive your results via email or text message?*

EmailText
Have you ever received professional help with skincare products/treatments?*

YesNo
If yes, what have you tried? Did you see a difference? When was your last treatment?
Do you need help with product, treatment recommendations or both?*

ProductsTreatmentsBoth
What steps do you currently have incorporated into your skincare routine?*

CleanseSecond cleanseExfoliateTonerSerumsEye creamsMoisturizerSpfAcne medication
If you checked any of the above, please list the brands.
Realistically, how many steps are you willing to commit to for your am/pm routine?*

Less than 3Less than 5Whatever it takes!
Which of these best describes your skin?*

DryOilyComboNormalSensitiveRosaceaAcne-proneHyperpigmentationMelasmaEczemaPsoriasisDark circlesUneven textureSun damagedOther
If you struggle with acne, is it year round or occasionally?

Year roundOccasionallyI don't struggle with acne.
How often do you exfoliate?*
If you don't exfoliate, type N/A
Please list all current medications (if any)
Please list all medical conditions (if any)
What are your overall skin goals, concerns, questions?*
How do you feel about your skin today?*

1

2

3

4

5

1 is Worst, 5 is Best
If you're looking to receive treatments, what days/times work best for you?
What's your skincare budget for products? I try my best to stay within that range. *
How did you hear about me?*
Please upload photos of your face in natural lighting so I can properly address your concerns.*

Right side, left side, front.
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