Current Lifestyle (Part 2 of 4)
These are questions we would ask in a spa for facials or product recommendations.
They help us eliminate products that would not work for you and give us guidance
as to what will work with your skin. Detailed questions are asked so we can get
a complete understanding of the skin (especially since we can’t see you!)
and recommend the absolute best possible solutions.
Do you smoke?
Yes No
How much water do you drink a day?
Are you pregnant, trying to become pregnant or breastfeeding?
Yes No N/A
Do you currently use any products with Retin-A or Vitamin A?
Yes No
If yes, what do you use it for?
Acne Fine lines Others
Do you or have you taken Accutane?
Yes No
If yes, when was your last course of Accutane?
Have you had facial surgery or laser/chemical peels in the last 3 months?
Yes No
Are you planning to?
Yes No
Current Skin Condition and Sensitivities (Part 3 of 4)
Skin Type, choose one *
Please select...
Normal Skin
Normal to Dry
Normal to Oily
Dry Skin
Oily Skin
Combination Skin
Acne prone
Skin Conditions
Dehydrated
Blackheads/Blemishes Hyper-pigmentation Acne scarring Rosacea Couperose Sensitive Fine lines Deep
lines and wrinkles Other (Please specify below)
Other
Please check all allergies/sensitivities:
None Aspirin Talc Retin-A Alpha Hydroxy Acids Beta
Hydroxy Acids Fragrances Iodine Seafood Nuts Sulphates Touch/Pressure Other
(Please specify below)
Other
The reaction is usually (check all that apply):
Anaphylactic Redness Itching Swelling Burning Hives Rash Tingling Eczema Blistering Flaking Other
(Please specify below)
Other
What specific products have you reacted to in the past?
Skin thickness
Please select...
Thick
Normal to thick
Normal
Normal to thin
Thin
If you have facial lines, where are you currently experiencing them?
Please select...
Around the eyes
Around the mouth
Eyes and mouth
Forehead
Whole face
Do you have eye area puffiness?
Please select...
Never
Sometimes
Frequently
All the time
Do you have undereye circles?
Please select...
Never
Sometimes, when I’m tired
Frequently
All the time
Which of these most describes your skin type?
Please select...
Very fair skin tone, blond or redhead,
freckles, burns easily, never tans.
Light skin tone, will tan, but usually
burns
Light to olive skin tone, sometimes burns,
hazel eyes, auburn to light brown hair.
Medium brown skin tone, rarely burns.
Dark brown skin tone, very rarely burns,
dark eyes, dark hair.
Dark skin tone, burn resistant, dark eyes.
Do you have broken capillaries?
Please select...
Problem (nose/chin/cheeks)
A few
None
Do you have blackheads?
Yes No
If so, where?
Do you experience redness in your skin? If so, what usually triggers it?
Other
Current Product Usage (Part 4 of 5)
What products do you currently use in your daily regime? (check all that apply)
Cleanser Toner Exfoliant Day Moisturizer Night
Moisturizer Mask Serum Eye Cream Other
(Please specify below)
What type of cleanser do you currently use?
Soap Milk Foaming Oil Lotion Other
(Please specify below)
Other
What product lines are you currently using for your skin care?
Are you happy with the results? If not, why?
Have you used products containing Glycolic Acid before?
Yes No
If yes, what percentage?
What makeup line are you currently using?
Do you wear sunscreen everyday?
Yes No
How do you use sunscreen?
I apply
a separate SPF product I use a moisturizer containing SPF I use
mineral makeup
Men, do you experience irritation while shaving?
Yes No
What do you currently shave with?
Desired Results (Part 4 of 5)
What results are you looking for?
Clear up Acne
Clear
up blackheads Minimize size of pores Decrease
oiliness of skin Diminish the appearance of capillaries on the face Lighten
skin complexion or hyper-pigmentation areas Restore
skin elasticity Hydrate the skin Smooth skin texture Diminish
flakiness of skin Lighten Acne scarring Diminish
wrinkles and fine lines Pre-facial surgery skin preparation Post-facial
surgery skin care Eliminate Redness/sensitivity Brighten
the skin tone Control Rosacea
Is there a particular philosophy of brand that appeals to you?
No preference Aromatherapy
base Botanical base Marine base Dermatological
base Natural/Organic
Are there any particular lines you would like to be recommended?
Please select...
No preference
Aromatherapy Associates
B. Kamins
Decleor
Guinot
Intaglio
MD Skincare
Phytomer
Skeyndor
Wilma Schumann
The very best available, regardless of
product line
Other (Please specify below)
Other
Briefly, state any concerns about your FACIAL care that were not addressed in the
previous questions.
What do you like or dislike most about your facial skin?
1.877.224.4315
