Name
              
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                    First Name 
                   
                
                
                  
                     
                    Last Name 
                   
                
               
            
            
            
            
            
            
        
          
          
            
            
            
            
            
              
                
            
              Email
              
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              Phone
              
             
          
                
                
                
                  
                     
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               How does your skin feel without applying any skincare products?
              
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                  Tight and dry
                
                  Balanced and comfortable
                
                  Oily and shiny
                
                  Oily in some areas, dry in others
                
               
            
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
               How often do you experience breakouts?
              
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                  Rarely
                
                  Occasionally (hormonal or stress-related)
                
                  Frequently, especially in certain areas
                
                   Almost always
                
               
            
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              How would you describe your pores?
              
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                  Small and barely visible
                
                  Medium-sized, only noticeable in certain areas
                
                  Large and visible all over
                
                  Large in the T-zone, smaller on the cheeks
                
               
            
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
               How does your skin react to new skincare products?
              
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                  Easily irritated, red, or sensitive
                
                  Usually fine, no major reactions
                
                  Sometimes experiences breakouts
                
                  Some areas react differently than others
                
               
            
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              How does your skin look by the end of the day?
              
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                   Flaky or dry
                
                  Still normal and even
                
                  Shiny and greasy
                
                  Oily in the T-zone, dry elsewhere
                
               
            
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              What is your primary skin goal?
              
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                  Hydration and reducing dryness
                
                   Anti-aging and firming
                
                  Controlling oil and breakouts
                
                  Brightening and evening skin tone
                
               
            
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              Do you struggle with hyperpigmentation (dark spots, uneven skin tone)?
              
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                  Yes, from acne scars or sun damage
                
                  A little, but not a major concern
                
                  No, my skin tone is even
                
                  I have some dark areas that don’t fade easily
                
               
            
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              How does your skin react to sun exposure?
              
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                  Burns easily, rarely tans
                
                  Tans evenly, rarely burns
                
                  Tans quickly but sometimes burns
                
                  Becomes more pigmented or develops sun spots
                
               
            
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              How does your skin react to sun exposure?
              
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                  Burns easily, rarely tans
                
                  Tans evenly, rarely burns
                
                  Tans quickly but sometimes burns
                
                  Becomes more pigmented or develops sun spots
                
               
            
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              How often do you experience redness or irritation?
              
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                  Frequently, my skin is very sensitive
                
                  Occasionally, but it goes away quickly
                
                  Rarely, my skin is pretty resilient
                
                  Only when using strong skincare products
                
               
            
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
               How often do you exfoliate?
              
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                  Rarely, my skin is too sensitive
                
                  Once or twice a week
                
                  Every other day or daily
                
                   I’m not sure
                
               
            
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              What skincare products do you use daily? (Check all that apply)
              
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                  Cleanser
                
                  Toner
                
                  Moisturizer
                
                  Sunscreen
                
                  Serums (Vitamin C, Retinol, etc.)
                
                   Exfoliators (AHAs, BHAs, scrubs)
                
               
            
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              How much water do you drink daily?
              
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                  Less than 2 glasses
                
                  3-5 glasses
                
                  6-8 glasses
                
                  9+ glasses
                
               
            
            
            
            
            
            
            
            
        
          
          
            
            
            
            
            
            
            
            
            
            
            
            
              
                
            
              Do you wear sunscreen daily?
              
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                  Yes, always
                
                  Sometimes, if I remember
                
                  Only when I’m in the sun for long periods
                
                  No, I rarely wear sunscreen