Free Skin Care Evaluation

Please complete the following form to enable us to give you a FREE skin care analysis, with recommendations on which products to use for YOUR skin.

Remember to complete EVERY field, to allow us to most accurately determine your needs. We will reply to your submission within 2-3 days, after our skincare professionals have evaluated your needs. 

Surname:

First Name:

Date of birth:

Address:

City:

Postal Code:

Email Address:

Tel:
(W) (H) (Mobile)
Gender
Male Female

1) Please list any medications you are currently taking including creams, over-the-counter and prescription medicines

2) Please list any chronic illnesses you may have, regardless how insignificant it might be

3) Please list any cleansers you are currently using

4) Please list all medical treatment you had recently, including surgery, laser treatment, acne treatment etc

5) Do you smoke? Yes No

6) Please list all your allergies e.g. penicillin, nuts etc

7) Are you allergic to any of the following: 
Retin A
Alphahydroxy Acids
Beta Hydroyacids
Fragrances
Hydrogen Peroxide

8) Do you currently take any vitamin or anti-oxidant supplements?
Yes No

9) Are you currently on Roaccutane or its equivalent?
Yes No

10) How much water do you consume per day?
Cups

11) Are you currently on a restricted diet?
Yes No

12) Does your skin turn red easily or stays red all the time?
Yes No

13) Are you on oral contraceptives?
Yes No

14) Are you pregnant or breastfeeding?
Yes No

15) Are you a male with ingrown hairs and irritation from shaving?
Yes No

16) Please state your preferred cosmetic house or skincare range

17) Please describe what you wish to treat (your skin problem), and what outcome you wish to have with regard to your skin

Please choose your skin type from the following headings and complete the questions per heading. You may choose as many options and answer as many questions as you wish to best describe your skin condition

 

My skin is:

Very fair, blond or redhead, freckles, burns easily, never tans
Light skin tone, some tanning but burns easily
Olive skin tone, some burning, hazel eyes, brown hair
Medium brown skin, rarely burns, dark hair, dark eyes
Dark brown skin, rarely burns, dark eyes, dark hair
Other: please describe


Sensitive Skin

I have a SENSITIVE SKIN best described as follows:
My skin is intolerant to irritants and is a combination skin (dry in areas and oily in the T Zone- forehead, nose and chin)
My skin is intolerant to irritants and is dry to very dry
My skin is sensitive with redness
My skin is sensitive, red and flaky


Dry Skin

I have a DRY skin best describes as follows:
My skin is dry and tight
My skin is dry, tight and itches
I have eczema/dermatitis/psoriasis
My skin has a dry, rough feel and needs moisturizing


Oily Skin

I have oily or combination skin with pimples and/or blackheads
I have oily, shiny skin and I need to matify it
I have oily skin that is acne prone
I have oily skin, but had recent dermatological treatment that left dryness
I have oily skin with imperfections (spots, pigmentation)


Irritated/Post Surgery Skin

My skin is irritated and chapped following a minor surgical or dermatological operation (post-peeling, laser, radiotherapy, definitive        depilation…).
I am looking for skin care that will restore my epidermis and relieve the discomfort caused by the lesions. There is no oozing from the        skin
As above, but there is oozing from the skin


Pigmented Skin

I have recent dark brown or pigmented spots on my face, neck or hands
I have pigmentation due to recent scarring or acne


Skin Preservation

My skin needs protection against daily exposure to detergents, chemicals, chafing or medicines
I have cracks on hands, feet, elbows or knees
My lips are cracked, chapped or damaged by medicines
I need a non irritating body deodorant and it must also be alcohol free


Anti Aging

I need a cream to limit wrinkle formation that is just starting
I need a cream for confirmed wrinkles
I need a cream prevent wrinkles around the eye area


Sun Protection

I have a normal to sensitive skin, and need very high sun protection factor
I have an oily skin, and need a very high sun protection factor
I am currently on skin treatment, and need the best sun protection
I need sun protection for a baby’s skin
I have an allergic-type skin and need sun protection
I need a self-tan, that does not require sun exposure
I need maximum sun protection for uneven skintone
I need maximum skin protection for the whole family
I need the best sun protection for my lips

Thank you for taking the time to complete this questionnaire. We will revert back to you in due course

What colour is the sky? (blue)


To prevent web form hacking, please answer the question above.

 
   
Business Solutions From Internet Technology Copyright Skinwellness | All rights reserved 2010