Name
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First Name
Last Name
Email
*
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