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Bloom Skincare Consultation
Please fill out the questionnaire for a custom tailored skincare routine sent directly to your inbox!
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If you would prefer to answer these questions via telephone, please schedule online at
www.vagaro.com/bloomskinstudio
Do you feel like your skin is:
Normal (feels the same most of the time, not too dry, not too oily)
Oily (by noon, there's a lot of oil on the skin, I have to blot a lot)
Dry (I swear my skin is like the Sahara Desert, it feels dry from the inside out)
Combination (My skin is usually dry on the cheeks and sometimes around the eyes and much more oily on the forehead, nose and chin)
I'm not sure (sometimes I think my skin is really confused)
Other:
Clear selection
Do you feel like your skin is congested (which means that you have clogged pores and dullness)?
Yes, my skin is very congested.
Yes, my skin is somewhat congested.
Yes, my skin is a little congested.
No, my skin is not congested.
Other:
Clear selection
Do you break out regularly?
I only break out around the time of my period.
I break out pretty regularly.
My skin always has blemishes and a lot of redness.
Yes, and I am concerned about scarring.
No, my skin rarely breaks out.
Other:
Clear selection
If you have a problem with breakouts, is your skin:
Really oily, congested and inflamed with a lot of redness
Feels dry, congested and inflamed with a lot of redness
Just feels dry and congested with an occasional breakout
Feels oily and congested without a lot of breakouts
My breakouts seem to come out of nowhere and they are deep and painful
Other:
Clear selection
What kind of breakouts do you normally get?
Small, red blemishes that are just annoying
Large, red, lesions that sometimes bleed
Small, pimple like bumps all over my face
Deep, painful, cystic blemishes
Other:
Clear selection
Where do you normally break out?
Forehead, chin and nose
Jawline and neck
Around my hairline
On my cheeks
On my back and chest
Other:
Clear selection
What kind of cleanser are you currently using?
A foaming cleanser
A cream cleanser
An oil cleanser
A cleansing lotion
A scrub
Other:
Clear selection
How often do you cleanse?
Morning and evening
Just morning
Just evening
Whenever I shower
I cleanse 3 times a day
Other:
Clear selection
Do you use scrubs or scrub brushes?
I never use a scrub
I use a scrub every day
I use a scrub a couple times a week
I use a scrub brush
I use a chemically exfoliating cleanser like one with glycolic acid or other AHA's (alpha hydroxy acids)
Other:
Clear selection
Do you use a toner?
Yes, I use a toner
No, I do not use a toner
I use witch hazel
I use rubbing alcohol
Other:
Clear selection
Do you use a moisturizer?
Yes, I moisturize my skin daily, it's like my religion
No, I do not use a moisturizer, I'm afraid it will make me break out
No, I do not use a moisturizer, I feel too lazy to do too many steps
No, I don't like the feel of moisturizer on my skin
Other:
Clear selection
Do you use any exfoliating acids on your skin that you are aware of?
Yes, I use glycolic acid (or any other acid) regularly
No, I do not use acids on my skin, I'm not sure what they do or which ones to choose
No, I don't understand the benefits of using acids on my skin
Other:
Clear selection
Do you use any retinol products on your skin?
I use products with retinol from the grocery store
I use a prescription retinol like Retin-A
I'm not sure what retinol is for
Other:
Clear selection
Do you use sunscreen?
Yes, religiously
No, I hate the feel of sunscreen
No, I seem to forget to use it every day
No, I am sensitive to sunscreen
No because I am indoors most of the time
Other:
Clear selection
Do you have brown spots on your skin?
Yes I have a lot of small brown spots
Yes, I have large patches of brown pigment
Yes, I have brown spots and nothing seems to help fade them
No, but I have red spots that take a while to fade
No, I don't have any trouble with brown spots
Other:
Clear selection
Are you on hormones of birth control?
I am on the pill
I have a birth control implant
I have an IUD
I am on hormone replacement
No, I am not on any sort of hormones
Other:
Clear selection
If you are on any hormones, have you noticed any changes in your skin since taking them?
No, I haven't noticed a difference
Yes, my skin has improved
Yes, my skin has gotten worse
I am not sure
Other:
Clear selection
Are you concerned with fine lines and wrinkles on your skin?
Yes
No
No opinion
Other:
Clear selection
If you are using anti-aging products, what are you using?
retinols
acids
peptides
vitamin c
niacinamide
Other:
Clear selection
What kind of anti-aging treatments have you done?
chemical peels
microneedling
laser
plastic surgery
Other:
Clear selection
How do you like your skin to feel most of the time?
dewey and hydrated
matte without shine on the skin
dry
no opinion/don't know
Other:
Clear selection
Do you feel like your skin is sensitive? Does it get red, irritated, or rashy easily?
Yes
No
Sometimes
no opinion/don't know
Other:
Clear selection
Are you sensitive or allergic to any scents or ingredients? Please note under "other" if you have sensitivities or allergies.
Yes
No
Not sure
Other:
Clear selection
Do you have any underlying health conditions that might affect your skin?
Your answer
Are you on any topical or oral prescriptions that make you sun-sensitive? Please list any under "other".
Yes
No
Other:
Clear selection
Do you have rosacea or any other diagnosed skin condition?
Yes
No
Not sure
Other:
Clear selection
What price point do you like to stay under when purchasing skincare?
Best regimen under $50
Best regimen under $75
Best regimen for under $100
Best regimen for my skin regardless of price
Other:
Clear selection
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