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LATHER Skin Care Questionnaire
Lather Lends a Hand Event with Junior League of Long Beach
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Name and Email Address:
Your answer
If any, what skin problems or concerns would you like to address?
Your answer
Please list any allergies you may have.
Your answer
Do you follow an at home skin care regimen?
Yes
No
Clear selection
Check the items you would like to use for your home skin care regimen.
cleanser
toner
daily moisturizer
facial scrub/exfoliant
mask
night cream
AHA products
serums
Describe how your skin feels and looks from your neck to forehead (check all that apply).
dry or rough
oily all over
acne flare ups
oily on forehead and nose
dry cheeks
lines and creases
uneven skin tone/texture
How often do you breakout?
never
rarely
monthly
consistently
Clear selection
Skin sensitivities (check all that apply).
itchy or tight after cleansing
dry
redness prone
blotchy
easily irritated
Which describes the look of your pores the best?
Small, not noticeable
Large and very visible on or around the T-zone
Medium-sized on entire face
Fine, no issues
Clear selection
What would you say is your main skin care goal? (check all that apply).
clear acne
reduce oil
even out skin tone and texture
brighter complexion
reduce fine lines and creases
increase hydration
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