The SkinBorn® Analysis Questionnaire

SkinBorn® successfully treats adult acne, eczema, whiteheads, blackheads, and pimples with our medical skin enhancement system.

Use the following form for a FREE personal skin care analysis done by one of our professional estheticians. The results will give you understanding to exactly what you need to solve your skin-related problems. SkinBorn® will send you an evaluation and product recommendations specifically designed for your skin.

The following analysis will help you make informed decisions about how to customize your skin care regime. To ensure a complete evalution of your skin please make sure that you answer every question on the form below.

Privacy Statement: The information you provide in this analysis is completely confidential and used only for analysis.

Contact Information

Name:
Address:
City:
State/Province:
Zip/Postal Code:
Country:
Email:
Phone:
How did you find our website? Direct Mail Newspaper Ad
TV Commercial If other please specify:

The Basics

Your Age: Your Sex: Female Male

Facial Surgery

1. Have you had microdermabrasion or facial plastic surgery in the past 3 months? Yes No
2. Are you planning to have microdermabrasion soon? Yes No

Lifestyle

3. Do you smoke? Yes No
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? Yes No
6. Do you use Retin-A? Yes No
If Yes: What do you use it for? Acne Fine Lines
7. Do you have irritation, sensitivity, flaking from Rentin-A use? Yes No
8. Are you currently using the Acne drug Accutane? Yes No
9. If no, have you used Accutane in the past? Yes No
10. If you have used it in the past, how long ago?
11. Are you currently on a restricted diet? Yes No
12. Do you excercise regularly? Yes No
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? Yes No

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? Yes No
18. Do you use any skin care products which contain mineral oil, lanolin, alcohol, color, fragrance, or formaldehyde? Yes No
19. What type of skin do you have? (Check one.)
Dry
Normal to Oily
Normal to Dry
Oily
Normal
Problem/Blemished

Women Only

20. Are you taking an oral contraception?
Yes No
21. Are you pregnant, trying to become pregnant, or breast feeding?
Yes No

Men Only

22. Do you ever experience irritation from shaving?
Yes No
23. Do you experience ingrown hairs?
Yes No

Oil Secretion

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
Totally Dry
I do not experience breakthrough oily shine during the day
25. Do you experience skin break-outs? Yes No

Moisture Hydration

26. How much water do you drink daily?
1-2 cups 3-4 cups 5-6 cups 7+ cups

Capillary Activity

27. Do you have a tendency to show redness in skintone? Yes No

Skin Type

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? No
Occasionally
Frequently
31. Do you have dark undereye shadows? Seldom
Occasionally
Frequently
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
Problem
34. Do you have small, red broken capillaries that show through your foundation?
Problem (nose / cheeks / chin) A few None
35. Does your skin have dry patches? Never
Occasionally
Frequently
36. Is your skin extremely dry? Yes No
37. Your skin pore size: Enlarged all over
Some enlarged in the T-zone
Nearly invisible
38. Your skin thickness: Very thick
Normal
Very thin
39. Do you wear glasses? Yes No

Almost Done!

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.
Cleansing Group
Moisturizing Group
Therapeutic Group
Treatment Group

© 2005 PAI Medical Group®. All rights reserved.