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What are your current skincare goals? What issues would you like to address?
What kind of breakouts do you experience?
Cysts - subsurface, red, painful
The classic pimple
What skincare products are you currently using?
How do you feel they are working well for you?
What statement best describes your skin. (Check all that apply)
My skin feels pretty good and is not overly oily or dry
My skin sometimes feels dry like the desert
My skin starts out okay in the morning, but dries out as the day goes on
My skin feels dry even after I use moisturizer
My cheeks feel dry and sometimes look flaky
My skin is pretty oily
My skin is oily only in the T-zone
Moisturizers can be too much for my skin
My skin starts to look shiny as the day goes on
My skin looks dull and lacks vitality
What is your morning skincare routine?
What is your evening skincare routine?
Do you have any allergies to skincare products? If so, what are they?
What happens when you have a reaction?
How much time do you spend in the sun? Check all that apply
0-30 minutes per day
1-2 hours per day
2-3 hours per day
3-4 hours per day
4+ hours per day
Do you use sunscreen? YesNo
If yes, how often do you reapply?
What brand do you use and what is the SPF?
Have you ever had a reaction to sunscreen products?
If yes, what was the brand and what was the reaction?
Do you have any dietary restrictions or allergies? If so, what are they?
Do you notice any seasonal changes in your skin? If so, please explain?
Do you exercise? YesNoWhen I can, no set routine
Do you clean your face before and after exercise? YesNoSometimes
What do you use to clean your face after exercise?
Do you currently smoke? YesNoSometimesNot anymore
How much water do you drink in a day?
Please list any prescription medications you are currently taking
Do you have any diagnosed conditions?
Is there anything else you would like us to know?
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