Skin Analysis-- About Face Boutique

Name:     

Address: 

City:         State: Zip:

E-mail:       Phone:

AGE GROUP

  Enter your age group less than 20 20-40 40-50 50-60 over 60                                                      

CLIENT HISTORY

1. Are you currently or within the last year under a physician's care?

yes  no

2.  Have you undergone any surgery in the last nine months?

yes  no

If yes, specify

3.  Have you had any of these health problems past or present?

cancer  diabetes  epilepsy   heart problem  hormone imbalance

 hysterectomy  thyroid  varicose veins

4.  List any medications and vitamins you take regularly.

Medications:

Vitamins:

5.  Do you:

smoke?                                                                           yes  no

use Retin-A?                                                                   yes   no

ever use the acne drug, Accutane?                                   yes   no

follow a restricted diet?                                                    yes  no

exercise regularly?                                                             yes  no

have regular sleep patterns?                                              yes  no

have your hair frosted, highlighted or chemically treated?   yes  no

wear contact lenses?                                                          yes  no

6.  What temperature of water do you use to cleanse with?

Cool Warm Hot

7.  Do you have any special skin problems?

yes  no

If yes, tell us about your special problems, concerns that effect your skin:

8.  What types of skin care products are you currently using?

soap  toner  masque   cleanser  moisturizer  scrub/peel

9.  What skin type are these products?

dry normal to dry normal normal to oily oily problem/blemished

10.  Please list the brand names of all your current skin care products:

FEMALE CLIENTS ONLY

11.  Are you taking oral contraception?

yes  no

12.  Are you pregnant or trying to become pregnant?

yes  no

MALE CLIENTS ONLY

13.  What is your current shaving system?

wet  electric

14.  Do you ever experience irritation from shaving?

yes  no

15.  Do you experience ingrown hair?

yes  no

OIL SECRETION

16.  Do you experience breakthrough oily shine during the day?

yes  no

17.  Do you experience skin break-outs?

yes  no

MOISTURE HYDRATION

18.  How much plain water do you consume daily?

I do not drink water 1 glass of water 2-5 glasses of water 6-10 glasses of water over 10 glasses of water

19.  Do you take laxatives or diuretics?

yes  no

20.  Do you experience these conditions on your skin?

flakiness  tightness  obvious dryness

21.  If you sunbathe, do you use a sunscreen/sun block on your skin?

yes  SPF #   no

CAPILLARY ACTIVITY

22.  Do you burn easily in moderate sunlight?

yes  no

23.  Do you blush easily when nervous?

yes  no

24.  Do you have a tendency to redness in skin tone?

yes  no

25.  Have you ever suffered any sinus problems?

yes  no

NERVE ACTIVITY

26.  How many cups of caffeine-type beverages (coffee, tea, soft drinks) do you drink daily?

1-3 cups  4 or more    

27.  Do you take any stimulants or slimming tablets?

yes  no

28.  Have you ever had a reaction to a stimulus such as these?

cosmetics metals pollen foods animals fragrance

SKIN TYPE

29.  Which of the following most closely describes your skin type?

Very fair skin, blond or redhead, freckles, burns easily Light fair skintone, will tan, usually burns White to olive skin tone, hazel eyes, auburn to light brown hair Medium brown skin tone, rarely burns Dark brown skin tone, very rarely burns, dark eyes, dark hair African-American, very dark skin and eyes, burn resistent

SKIN QUALITY

30.  Facial Lines:  a few or none some around the eyes around the eyes and the face

31.  Do you have eye area puffiness?no occasionally frequently

32.  Do you have dark under eye shadows? seldom occasionally frequently

33.  Your skin texture is: bumpy and uneven smooth and soft coarse and grainy

34.  Do you have blackheads?  few or none some in the T-zone problem

35.  Your skin pore size:  enlarges all over some enlarged in the T-zone nearly invisible

36.  Your skin thickness:  very thick normal very thin

37.  Do you wear glasses?  yes   no

38.  What results/improvements are you looking for?

BY SUBMITTING THIS FORM I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE FOLLOWING:    

This questionnaire submitted online, by mail or fax, cannot substitute for the completeness of an in-person consultation with a licensed professional skin care esthetician or doctor.  The About Face Boutique will analyze your skin type and suggest products solely on the completeness and accuracy of the information provided by you.  Any products purchased by you, in response to our suggestions based on information you have provided in this form are your responsibility and cannot be returned to The About Face Boutique.

Send your Skin Analysis Questionnaire by pressing the submit button above or via:

Fax:  727-789-4098

Mail: 

About Face Boutique

35080 US Hwy 19 North

Palm Harbor, FL  34684