How did you find our website?
TV Commercial If other please specify:
1. Have you had microdermabrasion or facial plastic surgery in the past 3 months?
2. Are you planning to have microdermabrasion soon?
3. Do you smoke?
4. Do you have allergies to any of the following? (Check all that apply.)
Aspirin Talc Clindamycin Retin-A Hydroquinone Alpha Hydroxyacids
Beta Hydroxyacids Fragrances Hydrogen Peroxide No allergies to the above
5. Do you currently take any antioxidant supplements?
6. Do you use Retin-A?
What do you use it for?
Acne Fine Lines
7. Do you have irritation, sensitivity, flaking from Rentin-A use?
8. Are you currently using the Acne drug Accutane?
9. If no, have you used Accutane in the past?
10. If you have used it in the past, how long ago?
11. Are you currently on a restricted diet?
12. Do you excercise regularly?
13. What water temperature do you normally cleanse with?
Cool Warm Hot
14. Do you have any special skin problems? (Check all that apply.)
I have adolescent Acne eruptions
I have adult onset Acne
I have deep cystic Acne
I have oily skin, but no eruptions
I have dry skin with Acne outbreaks
I have lines and wrinkles from sun damage (photoaging)
I have combination skin, dry in some places, oily in the T zone
I have hyperpigmentation (brown spots from sun or Acne)
I have Acne scarring
I have smooth, normal skin
I have enlarged pores
I have no special skin problems
15. Are you susceptible to cold sores?
Your Current Skin Products
16. What types of cleansers are you currently using?
Soap Cleanser Lotion Cream
17. Are you currently using bar soap to cleanse your face?
18. Do you use any skin care products which contain mineral oil, lanolin, alcohol, color, fragrance, or formaldehyde?
19. What type of skin do you have? (Check one.)
Normal to Oily
Normal to Dry
20. Are you taking an oral contraception?
21. Are you pregnant, trying to become pregnant, or breast feeding?
22. Do you ever experience irritation from shaving?
23. Do you experience ingrown hairs?
24. What time of day do you first notice oil?
15 to 30 minutes after cleansing
Midmorning 9 to 10 am
Lunch time 12 pm
Midafternoon 2 to 3 pm
Late Day 4 to 5 pm
I do not experience breakthrough oily shine during the day
25. Do you experience skin break-outs?
26. How much water do you drink daily?
1-2 cups 3-4 cups 5-6 cups 7+ cups
27. Do you have a tendency to show redness in skintone?
28. Which of the following most closely describes your skin type?
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.
Skin Quality - Please tell us about the following qualities of your skin:
29. Facial Lines:
Few or none
Some around the eyes
Around the eyes and on the face
Around the lip area
30. Do you have eye area puffiness?
31. Do you have dark undereye shadows?
32. Your skin texture is:
Bumpy and uneven
Smooth and soft
Coarse and grainy
33. Do you have blackheads?
Few or none
Some, especially in the T-zone
34. Do you have small, red broken capillaries that show through your foundation?
Problem (nose / cheeks / chin)
35. Does your skin have dry patches?
36. Is your skin extremely dry?
37. Your skin pore size:
Enlarged all over
Some enlarged in the T-zone
38. Your skin thickness:
39. Do you wear glasses?
40. What results are you looking for?
Clear up Acne eruptions
Clear up blackheads
Minimize size of pores
Decrease oilyness of skin
Restore skin elasticity
Hydrate the skin
Smooth skin texture
Diminish flakiness of skin
Lighten Acne scarring
Diminish the appearence of facial capillaries
Lighten complexion / hyperpigmentation areas
Diminish wrinkles and fine lines
Pre-facial surgery skin preparation
Post-facial surgery skin care
No special results, the best regimen for my skin
Briefly, is there anything else about your FACIAL skin that was not addressed by the questions above:
What do you like best about your facial skin?
What do you like least about your facial skin?
BY SUBMITTING THIS FORM I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE FOLLOWING:
This questionnaire submitted online cannot substitute for the completeness of an in-person consultation with licensed professional skin care estheticians or doctors. The estheticians of SkinBorn® Clinics analyze your skintype and suggest products soley on the completeness and accuracy of the information provided by you. Any products purchased by you, in response to SkinBorn.com suggestions based on information you have provided in this form, are your responsiblility and cannot be returned to SkinBorn.com.