Skincare Questionnaire

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Name


Email


1) What's your birthday? Month, day, and year please.


2) Where do you live? Please name the location and even give a brief description of your area (on the beach, the city, the desert, high elevation, etc)


3) Check your TOP FIVE skin care concerns.

In the box below, rank your concerns by listing the corresponding letter, 1 being your biggest concern, 5 being mild concerns.

For Example: 1- K, 2- J, 3- C, 4- O, 5- G


















4) Use a clean, damp washcloth to cleanse your face, gently pat dry and wait 10 minutes. Describe your skin. (Choose up to three answers.)








5) Three months after you're injured, your scars are



6) Does sun exposure make you freckle?



7) Describe your current skincare routine.

Check all the products you use on a regular basis, and use the blank field below to describe any other products you like and how often you use your products.

If you are low maintenance and don't use any product, you can put that in the blank field too!














8) What allergies do you have? (Nuts, ragweed, bees, etc)