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Skin Evaluation

I. Evaluating for Cleansers and Lotions

Check all that apply:











II. Basic Care / Specialized Care / Intensive Care

Approximate age:







Lifestyle (select all that apply):

Taking dermatologist prescription drugs
 Fine textured skin (tight pores)
Taking other prescription drugs
Extreme temperatures (work environment)
Eat out 50% of the time
 Fly frequently
Microwave 20% of the food you eat
 Poor elasticity (face and or neck)
Smoke
 Noticeable lines around eyes
Consume Coffee (regularly)
 Noticeable lines around mouth
Drink Soda (regularly)
 Noticeable lines across forehead
Sun damage (brown spots)
 Cosmetic surgery
Freckles
 Botox
Dark complexion
 Acupuncture (on face)
Light to medium tone
 Tired complexion (even when well rested)
Red Hair (naturally)
 Hormone Replacement Therapy – prescription
Eat fish at least twice per month
 Hormone Replacement Therapy – natural
Discoloration around mouth (primarily)
 Diabetic
Vitiligo
 Retin A
Collagen shots Sun block 15 or above
Face peels Sun block during sun exposure only
Eyelid sagging Tanning salon
Under eye dark circles Self tanning crèmes
Under eye puffiness    
III. Body

Select all that apply:

Shower 75% of the time
Bath 75% of the time
Body lotion (nearly everyday)
Body lotion (never)
Body oil (never)
Back acne
Breast stretch marks
'Orange Peel’ thighs
Tired legs (even when not standing often)
Exercise at least 2x a week
Exercise at least 5x a week

IV. Water

0 – 16oz. per day
16 – 32 oz. per day
32oz. and above per day

IV. Your Information

Name:

E-mail:

 
 
 

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