1. Have you had laser resurfacing or facial Plastic Surgery in the past 3 months? Yes No
2. Are you planning to have facial resurfacing soon? Yes No
3. Are you planning to have eyelid surgery soon? Yes No
4. Are you planning to have other facial Plastic Surgery soon? Yes No

3. Do you smoke? Yes No
4. Do you have allergies to any of the following? (Check all that apply )
   

   Aspirin
   Talc
   Clindamycin
   Retin-A
   Hydroquinone
   

   Alpha Hydroxyacids
   Beta Hydroxyacids
   Fragrances
   Hydrogen Peroxide
   No allergies to any of the above

5. Do you currently take any antioxidant supplements? Yes No
6. Do you use Retin-A? Yes No
   If yes:
   What do you use it for? Acne Fine Lines
   Do you have irritation, sensitivity, flaking from Retin A use? Yes No
7. Are you now using the Acne drug Accutane? Yes No
   If no , have you used Accutane in the past? Yes No
   If you used it in the past, how long ago? Months.
8. Are you currently on a restricted diet? Yes No
9. Do you exercise regularly? Yes No
10. What water temperature do you cleanse with? Cool Warm Hot
11. 1. Do you have any special skin problems? (Check any that apply )
       I have adolescent Acne eruptions
       I have adult onset Acne
       I have oily skin, but no eruptions
       I have dry skin with Acne outbreaks
       I have lines and wrinkles from sun damage (photoaging)
       I have combination skin, dry in some places, oily in the T zone
       I have hyperpigmentation (brown spots from sun or Acne)
       I have Acne scarring
       I have smooth, normal skin
       I have enlarged pores
       I have no special skin problems
    2. Are you susceptible to cold sores? Yes No

12. 1. What types of cleansers are you now using?
       

       Soap
       Cleanser

       Lotion
       Cream

    2. Are you currently using bar soap to cleanse your face? Yes No
13. Do you use any skin care products which contain mineral oil, lanolin, alcohol, color, fragrance, or formaldehyde? Yes No
14. 1. What type of skin do you have?
       Dry Normal to Dry Normal Normal to Oily Oily
    2. What product line are you currently using?
    3. Have you used glycolic? Yes No Don't know
    4. If you've used glycolic, what percentage?

15. Are you taking oral contraception? Yes No
16. Are you pregnant, trying to become pregnant, or breast feeding? Yes No

17. Do you ever experience irritation from shaving? Yes No
18. Do you experience ingrown hairs? Yes No

19. What time of day do you first notice oil?

    15 to 30 minutes after cleansing
    Midmorning 9 to 10 am
    Lunch time 12 pm
    Midafternoon 2 to 3 pm
    Late Day 4 to 5 pm
    Totally Dry
    I do not experience breakthrough oily shine during the day

20. Do you experience skin break-outs? Yes No

21. How much plain water do you consume daily?
    1-2 cups 3-4 cups 5-6 cups 7+ cups
22. When you are in the sun for extended periods, do you use a sunscreen/sunblock? Yes No

23. Do you have a tendency to redness in skintone? Yes No

24. Which of the following most closely describes your skin type?

    Very fair skin tone, blond or redhead, freckles, burns easily, never tans.
    Light skin tone, will tan, but usually burns.
    Light to olive skin tone, sometimes burns, hazel eyes, auburn to light brown hair.
    Medium brown skin tone, rarely burns.
    Dark brown skin tone, very rarely burns, dark eyes, dark hair.
    Dark skin tone, burn resistant, dark eyes.

Please tell us about the following qualities of your skin:

25. Facial Lines:
    

    a few or none
    some around the eyes

    around the eyes and on the face
    around the lip area

26. Do you have eye area puffiness? No Occasionally Frequently
27. Do you have dark undereye shadows? Seldom Occasionally Frequently
28. Your skin texture is: Bumpy and Uneven Smooth and Soft Coarse and Grainy
29. Do you have blackheads? Few or None Some, Especially in the T-zone Problem
30. Do you have small, red broken capillaries that show through your foundation?
    Problem (Nose/Cheeks/Chin) A Few None
31. 1. Does your skin have dry patches? Never Occasionally Frequently
    2. Is your skin extremely dry? Yes No
32. Your skin pore size:

    Enlarged all Over Some enlarged in the T-zone Nearly Invisible

33. Your skin thickness: Very Thick Normal Very Thin
34. Do you wear glasses? Yes No

35. Please choose skin care issues that you would like help with.

    Clear up Acne eruptions
    Clear up blackheads
    Minimize size of pores
    Decrease oilyness of skin
    Diminish the appearence of capillaries on the face
    Lighten skin complexion or hyperpigmentation areas
    Restore skin elasticity
    Hydrate the skin
    Smooth skin texture
    Diminish flakiness of skin
    Lighten Acne scarring
    Diminish wrinkles and fine lines
    Pre-facial surgery skin preparation
    Post-facial surgery skin care
    No special results, just a regimen for my skin

36. What product line would you like for us to recommend for you?
    

    Belli
    Bioelements
    DCL
    Dermaheal
    Dermalogica Cosmeceuticals
    Exuviance
    glo minerals makeup
    GreatSkin
    IS Clinical

    LaRoche-Posay
    NeoCutis
    Neostrata
    Peter Thomas Roth
    Rhonda Allison
    Your pre-facial surgery skin prep program
    Your post-facial surgery skin care program
    Dr Brandt
    I would like the GreatSkin skin care professionals to choose the most effective products for my skin type

37. In summary,
    
    1. What do you like best about your skin?
    2. What do you like least about your skin?
38. Are you interested in receiving the GreatSkin Newsletter?
    Yes, I would like to subscribe to the GreatSkin Newsletter!

BY SUBMITTING THIS FORM I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE FOLLOWING:
This questionnaire submitted online cannot substitute for the completeness of an in-person consultation with licensed professional skin care estheticians or doctors. The estheticians of Physicians GreatSkin® Clinics analyze your skintype and suggest products soley on the completeness and accuracy of the information provided by you. Any products purchased by you, in response to GreatSkin®.com suggestions based on information you have provided in this form, are your responsiblility and cannot be returned to GreatSkin®.com.

IMPORTANT! You must provide an answer to every single question on this form in order for it to be accepted.