Questionnaire | Clear Complexion

SKINCARE QUESTIONNAIRE

First name

Last name

Phone

Address

Occupation

Birthday

Month

Day

Year

Ethnicity

Have you been on any dermatologist prescribed acne medications? If so, what medication and how long ago?

When was the last time you were on an antibiotic?

Do you take any medications or supplements? Please list:

Any known medical conditions:

Have you ever had a reaction to any products you have put on your face?

Please list any allergies you have to foods, ingredients, ect. Or leave blank.

Name of laundry detergent, dryer sheets and fabric softener - if applicable.

Do you swim in a chlorinated pool on a weekly basis?

What would you rate your current stress levels? (common stress = new job, wedding, heavily scheduled, difficult home life)

What skin concerns do you have?

How would you best describe your skin type?

How long have you been experiencing break outs? If applicable.

How would you describe your break outs? If applicable.

What is your skincare routine? Please list every product you use by name. This is vital to the process.

Do you wear makeup? If so name/brands and how often.

Do you smoke/vape?

Women: Are you currently using Birth Control pills, shots, or use an IUD? If so name/brand:

Women: Are you pregnant or breastfeeding?

Are you currently getting regular facial treatments done with an esthetician? If so when was your last treatment?

Do you ever pick at your skin?

What is your diet like? Please describe.

Any food intolerances?

Do you drink alcohol or soda? if so how much weekly?

How much water do you drink a day?

How many hours of sleep do you normally have?

Do you exercise regularly?

Do you know of any possible triggers for your skin?

Please submit 3 photos of your skin without makeup in natural lightening (one left side, right side and center):

Thank you for taking the time to thoroughly fill out this questionnaire. As soon as we receive it, we will reach out to schedule your FREE virtual consultation before moving onto next steps.