Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
E-mail

Do you have any special skin problems pertaining to your face or body?

Yes No

If yes, please specify.

What skin care products are you currently using?

Soap
Cleanser
Moisturizer
Masque
Exfoliator
Eye Products
Others

Have you ever had any chemical peels or dermabrasion?

Yes No

If yes: In the last month?

Yes No

Do you use Retin A, Renova or Adapalene?

Yes No

If yes: In the last month?

Yes No

Do you use any acne medication?

Yes No

If yes, which drug?

Please select any of the following products or ingredients you are currently using.

Glycolic Acid
Lactic Acid
Any Exfoliating Scrubs
Any Hydroxy Acid Product
Vitamin A Derivatives (i.e. retinol)

Do you experience any of the following conditions on your skin?

Flakiness
Tightness
Obvious Dryness
Burning Itching Sensation

Do you have a tendency towards redness?

Yes No

Do you burn easily in moderate sunlight?

Yes No

Do you ever experience an oily shine during the day?

Please select one Yes No Occassionally

Do you ever experience skin breakouts?

Please select one Yes No Occassionally