Name::
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Daytime Telephone No.:
Alternate Telephone No.:
E-mail::
What skin care problem do you need help with ?:
Do you need help determing skin type ?:
Do you need help determining skin condition:
Do you use the same soap on your face as your body ?:
Are you male or female ?:
What is your ethnicity ?:
What is your age ?:
How many times you cleanse your face ?:
Do you use tonors, astringents, tonics?:
Do you use a sunscreen daily on your face ?:
Do you use moisturizers on your face ?:
Do you use masques or scrubs ?:
Are you using a topical medication prescribed by your doctor on your face ?:
What cleanser do you cleanse your skin with ?:
Are you pregnant ?:
Do you take medications for hypertension, diabetes, cholesterol, hormones ?:
Any health conditions ?:
Do you have any uneven skin tone ? dark marks ?:
Do you have acne and dry skin ?:
Do you have acne and oily skin ?:
Do you have allergies ?
Do you have exema on your face ?:
Do you consume caffeine, tea, chocolate ?:
How much water do you drink daily ?:
Do you daily eat meat and/or dairy products ?:
Do your exercise regularly ?:
Is your skin type Dry, Oily, Combination, Normal?:
What are your Skin Conditions ? Mature, Sensitive, Oily/Asphyxiated, Acneic, Uneven ?:
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