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Usefull information

Personal Skin Type Test

Skincare Questionnaire

First Name

Last Name

Email Address

Age

Do You Live in the United States?

Yes No

What City Do You Live In?

What State/Country Do You Live In?

Tell us about your climate. Is it hot, cold, windy, dry, humid, etc.

Select the type of skin you believe you have
Skin Type	Skin Characteristics
Very Dry	Dry all over--all the time, tight, easily irritated
Dry/Mature	Mostly dry, tight, maturing or sun-damaged, loss of softness/suppleness
Normal to Dry	Normal to Oily in the T-Zone, Dry on the sides of the faced
Normal	Slightly Oily in the T-Zone, Normal on the sides of the face
Normal to Oily	Oily in the T-Zone, Normal to oily on the sides of the face
Oily	Very Oily in the T-Zone, slightly oily on the sides of the face
Very Oily	Very Oily all over--all the time, prone to breakouts but not necessarily problem/blemished
Blemished	Oily all over with frequent problem breakouts

Is your skin sensitive or easily irritated by products?

Yes No

Do you use a regular skincare routine now?

Yes No

What brand of products and specifically which products do you use now?

Where do you currently purchase your skincare products?
Purchase Location	Sample Brands
Salon or Spa	AFE, Murad, MD Formulations, Dermalogica, Babor, SkinCeuticals, etc.
Department Store	La Prairie, Estee Lauder, Lancome, Clarins, Erno Laszlo, Clinique, Shiseido, etc.
Drug Store	L'Oreal, Almay, Cetaphil, Oil of Olay, Neutrogena, Clean & Clear, etc.
Direct from a Rep	Mary Kay, Beauticontrol, Avon, Amway, etc.
Don't Use Any Skincare Products

What type of cleanser do you use now?

Cream Lotion Soap

Does your face feel tight at times?

Yes No

How do you view your skin? Tell us about problems, concerns, etc. that affect your skin.

Do You have Facial Lines?

A Few or None
Some Around the Eyes
Around the Eyes/On the Face

Facial Lines Are

None
Just Starting
Noticeable, but Not Bad
Very Noticeable

Facial Lines are located

Eye Area (Corners of Eyes, Under eyes)
On the Forehead
From the nose to mouth and on the Face
Around the mouth and lips
On the Throat

Do you have Blackheads?

None/Seldom
Ocassionally
Frequently
Problem

Does your skin blemish/break out?

Never
Seldom/Occasionally
Frequently
Always/Problem

Describe your Pore Size

Nearly Invisible
Some Enlarged
Enlarged in T-Zone
Enlarged All Over