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Skin Questionnaire

Name:
 
Address:
 
Date of Birth:
 
Email:
1. What are your main skin concerns?
Oilness
 
Dryness
 
Skin Ageing
 
Acne
 
Sensitivity
 
Skin Tone
 
2. List any medications, supplements, vitamins, diuretics, slimming tablets etc that you are taking or have taken within the last 6 months
 
3. Do you smoke?
 
4. Do you exercise regularly?
 
5. Do you follow a restricted diet?
 
6. Do you have a regular sleep pattern?
 
7. Do you have a particular skin problem with your face or body?

If Yes, Please Give Details:
 
8. Which products do you currently use?
Soap
 
Cleanser
 
Toner
 
Moisturiser
 
Masque
 
Exfoliator
 
Eye Products
 
Other
 
9. How much water do you consume daily?
 
10. How many alcoholic beverages do you consume weekly?
 
11. Do you use sunbeds or sunbathe regularly?
 
12. How many caffeinated beverages do you consume daily?
 
13. Have you ever had any type of allergic reaction? If yes please give details
 
14. Do you use (or have you used within the last 6 months) Accutane, Retin A, Renova, or Adapalene? If yes please give details