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Skin Care Questionnaire
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Name
Your answer
Phone
Your answer
Do you have sensitive skin?
Yes
No
Do you have sun damage?
Yes
No
Describe your skin
Oily
Dry
Combination
Do you have acne?
Yes
No
Do you have discoloration?
Yes
No
Do you have fine lines and wrinkles?
Yes
No
Do you have large pores
Yes
No
Do you have dark circles?
Yes
No
Do you have baggy, loose skin?
Yes
No
Do you have puffiness under your eyes?
Yes
No
What is your current skin care regimen including products used?
Your answer
What are your skin goals?
Your answer
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