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Questionaire
Prescription
A
.Age Range:
Under 20
21 - 30
31 - 40
41- 50
Over 50
B
.Your skin care concerns:
Check all that apply
Fine lines and wrinkles
Age spots, pigmentation
Dryness, dehydration
Oiliness
Break Outs
Facial redness/sensitivity
C
.Do you use any of the following topical products?
Retin A or Retin A Derivatives
AHA and BHA Products (glycolic, lactic, salycilic acids)
D
.SUN TYPE CLASSIFICATION SYSTEM
White
Always burns, never tans
White
Usually burns, tans less than average
White
Sometimes burns mildly, tans about average
Brown
Rarely burns, tans more than average
Brown
Rarely burns, tans profusely
Black
Never burns, deeply pigmented