GreatSkin® Analysis Questionnaire
For Product Recommendation

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 required
4. Do you have allergies to any of the following? (Check all that apply; required: You must select at least one)
   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 required
6. Do you use Retin-A? Yes No required
   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 required
   If no , have you used Accutane in the past? Yes No
   If you used it in the past, how long ago?
8. Are you currently on a restricted diet? Yes No required
9. Do you exercise regularly? Yes No required
10. What water temperature do you cleanse with? Cool Warm Hot required
11. 
    
    1. Do you have any special skin problems? (Check any that apply; required: You must select at least one)
       I have adolescent Acne eruptions
       I have adult onset Acne
       I have deep cystic 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 required

12. 
    
    1. What types of cleansers are you now using? ( required: You must select at least one or we will not be able to process your skin analysis)
       Soap
       Cleanser
       Lotion
       Cream
    2. Are you currently using bar soap to cleanse your face? Yes No required
13. Do you use any skin care products which contain mineral oil, lanolin, alcohol, color, fragrance, or formaldehyde? Yes No required
14. 
    
    1. What type of skin do you have? (Check one.) required
       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 required
    4. If you've used glycolic, what percentage?

If you selected female above, you must answer both of these questions
15. Are you taking oral contraception?
    Yes No
16. Are you pregnant, trying to become pregnant, or breast feeding?
    Yes No

If you selected male above, you must answer both of these questions
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? required
    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 required

21. How much plain water do you consume daily? ( required: You must select one)
    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 required

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

24. Which of the following most closely describes your skin type? ( required: You must select one)
    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: required
    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? ( required: You must select one)
    no occasionally frequently
27. Do you have dark undereye shadows? required
    seldom occasionally frequently
28. Your skin texture is: required
    bumpy and uneven smooth and soft coarse and grainy
29. Do you have blackheads? required
    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 required
31. 
    
    1. Does your skin have dry patches? required
       never occasionally frequently
    2. Is your skin extremely dry? required
       Yes No
32. Your skin pore size: required
    enlarged all over some enlarged in the T-zone nearly invisible
33. Your skin thickness: very thick normal very thin required
34. Do you wear glasses? yes no required

35. Please choose up to three skin care issues that you would like help with. required: You must select at least one and no more than three
    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? (required: You must select one )
    Belli
    Bioelements
    Biomedic (You must already have a Greatskin.com patient password for these products)
    DCL
    Dermalogica
    GreatSkin
    IS Clinical
    Joey New York
    Kinerase
    LaRoche-Posay
    L'Occitane
    M.D. Forte
    Neostrata
    Obagi Nu Derm
    Obagi RX C
    Rhonda Allison
    Skinceuticals
    Skin Medica
    Stri Vectin
    TYK
    Your pre-facial surgery skin prep program
    Your post-facial surgery skin care program
    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? required
       
    2. What do you like least about your skin? required
       
38. Are you interested in receiving 'Greta, the GreatSkin Gal,' our free monthly ezine featuring the continuing romantic adventures of Greta and great monthly discounts on the GreatSkin products she recommends?
    Yes, I would like to subscribe to Greta!

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.