The Skin Shoppe Questionnaire

Skincare Questionaire

First Name

Last Name

Email(Required)

Phone(Required)

Gender(Required)

Male

Female

Skincare Questionaire

How would you describe your skin type?(Required)

Oily

Dry

Normal

Sensitive / Red

Do you have any specific skin concerns?(Required)

Acne

Blackheads / Whiteheads

Hyperpigmentation / Sun Damage

Melasma

Aging / Wrinkles

Rosacea

Eczema / Psoriasis

Large Pores

Dullness

Other (please specify)

Please specify your specific skin concerns.

Are you currently experiencing any skin irritation or conditions?(Required)

Yes

Please describe your current skin irritation or condition.

Please upload ONE front facing photo of your face(Required)

Accepted file types: jpg, png, Max. file size: 128 MB.

Please upload ONE left side photo of your face(Required)

Accepted file types: jpg, png, Max. file size: 128 MB.

Please upload ONE right side photo of your face(Required)

Accepted file types: jpg, png, Max. file size: 128 MB.

Skincare Questionaire

What products do you currently use and with what frequency?

Please upload ONE photo of your current products in a line with the label facing out in order of use(Required)

Accepted file types: jpg, png, Max. file size: 128 MB.

Are there any skincare products or ingredients you are allergic or sensitive to?(Required)

Yes

Please specify what skincare products or ingredients you are allergic or sensitive to

Skincare Questionaire

How would you describe your diet?(Required)

Balanced

High in processed foods

High in fruits and vegetables

Other

Please specify(Required)

Do you smoke cigarettes?(Required)

Yes

How much water do you drink daily?(Required)

Less than 1 liter

1 - 2 liters

More than 2 liters

How many hours of sleep do you get on average per night?(Required)

Less than 5 hours

5 - 7 hours

More than 7 hours

How often do you expose your skin to the sun?(Required)

Rarely

Occasionally

Frequently

Always wear sunscreen

Skincare Questionaire

Do you have any known medical conditions that might affect your skin? (e.g., diabetes, thyroid issues, hormonal imbalances)(Required)

Yes

Please specify any known medical conditions that might affect your skin? (e.g., diabetes, thyroid issues, hormonal imbalances)

Are you taking any medications that could affect your skin? (e.g., birth control, antibiotics, Accutane)(Required)

Yes

Please specify any medications that could affect your skin? (e.g., birth control, antibiotics, Accutane)

Skincare Questionaire

What are your primary goals for your skincare regimen? (e.g., clear acne, reduce wrinkles, even skin tone)(Required)

How much time are you willing to spend on your daily skincare routine?(Required)

Less than 5 minutes

5 - 10 minutes

More than 10 minutes

What is your skincare budget?(Required)

$100 - $200

$200 - $300

$300 - $400

I don’t have a budget, I want what is best for my skin

Is there anything else you would like your skincare professional to know about your skin or lifestyle?

Phone

This field is for validation purposes and should be left unchanged.