Skin Care Questionnaire

Do you need help determining which products will be best for you? Let us help! Complete the questionnaire below. One of our staff physicians will review your responses and determine which products you should use and provide a treatment regimen. Thank you for choosing Visage de Santé.

How did you find our Web site?		Search Engine Friend Advertisement
If other, please enter here:
Age
Sex		Female      Male
Do you smoke?		Yes      No
Do you exercise regularly?		Yes      No
What type of skin do you have?		Dry Dry to Normal Normal Oily Blemished/Damaged
What type of complexion do you have?		Fair skin – burns easily, never tans Light skin – will tan, usually burns White skin tone – occasionally burns,       light eyes, light color hair Olive skin – rarely burns Medium brown skin – rarely burns Dark brown skin – dark eyes and hair Black skin – never burns, dark eyes
Do you have special skin problems (check any that apply)		I have acne I have oily skin, but no acne I have dry skin with acne I have wrinkles and lines from        sun damage I have combination skin with dry        and oily places I have brown spots from sun damage        and/or acne
What type of facial cleansing products do you presently use?		Soap Cleanser Lotion Cream
Do you use a bar soap facial cleanser?		Yes No
Do you have facial lines?		None Few around eyes Around eyes and on face Around lips
Do you have puffiness around eye area?		Never Occasionally Often
Do you have dark shadows under your eyes?		Never Occasionally Often
Describe the texture of your skin		Soft/Smooth Uneven/Bumpy Rough/Grainy
Do you have blackheads?		None Some Many
Do you have broken, red capillaries?		None Few Many
Do you get dry patches on your face?		Never Occasionally Often
Is your skin very dry?		Yes No
What is your skin pore size?		Small/Nearly invisible Enlarged in areas Enlarged all over
What is your skin thickness?		Thin Normal Thick
Last Name
First Name
Street Address
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State
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email
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