Skin Analysis Form First name * Last name * Email * Age * Under 18 18-24 25-34 35-44 45-54 55-64 65 or Above Prefer Not to Answer Gender * Male Female Which of the following most closely describes your skin tone: * Very Fair, burns easily, never tans, freckles (typically red hair) Light Olive, sometimes burns (typically light to medium brown hair)ery Fair, burns easily, never tans, freckles (typically red hair) Light, burns first, then tans (typically blond hair) Medium Olive, rarely burns (typically Asian or Hispanic) Dark Brown, never burns (typically African-American) Which of the following most closely describes your skin tone: * Oily Skin, large pores – cheeks and T-zone are oily with enlarged pores and prone to blemishes Combination Skin, oily in the T-zone, dry/normal cheeks Normal Skin, overall good skin condition that is not dry or oily or sensitve Dry Skin, small pores, face fees dry and tight and could appear flaky or rough in patches Sensitive, skin is easily irritated and can have skin redness Does your skin break out? * Almost always Frequently Rarely Never How would you describe your skin? * Sensitive Resilient Not sure Do you have small, red, broken blood vessels on your face? * Yes No Do you spend a lot of time outdoors? * Yes No Do you wear sunscreen * Always Sometimes Never Do you go to tanning booths * Frequently Sometimes Never Do you have "age spots' or sun damage on your face? * Yes No Do you smoke? * Yes No Are you currently using Retin-A or Renova? If so, how long have you been using it? * Under 3 month 3 months - 1 year 1-3 years Over 3 years N/A Do you experience any irritation, dryness or flakiness from Retina-A * Yes No N/A Are you currently using the drug accutane? * Yes No Have you undergone laser skin resurfacing in the last 3 months? * Yes No Do you have allergies to any of the following? (Check all that apply) * Alpha-hydroxy Hydroquinone Preservatives Fragances N/A List any other known allergies: (optional) Are pregnant? * Yes No N/A Are you tying to become pregnant * Yes No N/A Are you taking oral contraceptives? * Yes No N/A Do you have a regular skin care routine now? * Yes No What type of cleanser are you using * Soap Gel Lotion Cream What line(s) of skin care products are you currently using? (optional) What kinds(s) of results are you looking for? (Check all that apply) * Diminish fine lines and wrinkles Improve texture of the skin Even out skin tone Hydrate the skin Clear up acne breakouts Decrease oiliness Lessen number of blackheads Lighten "age" spots Minimize size of pores Please list any additional concerns you would like for us to address: (Optional) Would you like to receive updates on special offers and promotions? * Yes No How did you find out about our website? (Optional) By clicking on the acceptance check box below, and submitting this form I acknowledge that I have read and understand the following: This questionnaire submitted online cannot substitute for the completeness of an in-person consultation with Advanced DermaCare. Advanced DermaCare will analyze my skin type and suggest products solely on the completeness and accuracy of the information provided. This is not an automated generated response to your inquiry. This is a personalized e-mail response from Advanced DermaCare , which you will receive within 1-3 business days of submitting. * I accept the terms. Reload Image Please check the required fields Your form has been sent. Thank you! Thank You For Taking Time To Fill Out Our Skin Questionnaire.