Free Skin Analysis

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Take our Skin Analysis and keep your skin looking beautiful longer!

In this fast paced, high pressured world, taking care of yourself is no longer a luxury—it is essential to your well-being. Learn the most effective skin care regimen for your skin by answering each of the following questions. A customized skin care routine will be designed especially for you.

(This information is strictly confidential and will only be used

for the purpose of skin analysis.)

Name:

Email: please include domain (example: you@YOURDOMAIN.COM )

What Climate Do You Live In?

Your age is: Under 19 19-25 26-35 36-45 46-59 +60

Sex Male Female

Are You Pregnant Or Trying To Become Pregnant? Yes No

Are You Taking Oral Contraceptives? Yes No

Are You Looking For: Basic Skin Care Acne Treatment Anti-Aging Treatments

What results are you looking to achieve? Check all that apply: Increased elasticity and firmness

Diminish fine lines and wrinkles Improved texture Even color/lighten hyper pigmentations

Brighten skin Soften and hydrate skin Clear up acne/lighten scarring from breakouts

Decrease shine and oily feeling Decrease clogged pores Minimize size of pores

Do you consider your skin to be: Dry Oily Combination

Shade of skin: Very Fair Light Light Olive Medium Olive Dark Brown

Is your skin: Sensitive Very Sensitive Not Sensitive

Are you allergic to: Alpha-hydroxy Acids Salicylic Acid Hydroquinone Sulpher

Preservatives Fragrances Iodine Sunscreens

Other Allergies:

Have you had an allergic reaction to a product or ingredient? Yes No

If so, what was it?

Do you frequently have: acne breakouts Clogged Pores Blackheads Whiteheads Cysts

Do you have: hyper pigmentations from sun damage? Do you use tanning booths?

Do you wear sunscreen? Do you have Rosecea?

Do you have broken capillaries? Do you smoke Or exposed to secondary smoke?

Are you exposed to workplace pollution? Do you take nutritional supplements?

Are you taking Accutane? What medications are you currently taking?

Are you using: Retin-A Renova Salicylic Acid If so, how long

Have you experienced any: Irritation Dryness or Flakiness

Are you currently under treatment from a Dermatologist? Yes No

If so, for what condition?

What products do you use? Make Up Dissolver Cleanser Moisturizer Toner Sunscreen

Self Tanner Scrubs Masks

Special Treatment Products:

What line of skin care products are you currently using:

What make-up products do you wear on a daily basis?

Do you have any other questions or concerns?

By submitting this form I agree that I have stated to the best of my knowledge all known physical conditions, as well as medications and hormone treatments which apply to my present health condition. I also understand that this questionnaire can not substitute the completeness of an in-person consultation with a licensed skin care professional.

Beauty Care Products | Qtica & OPI Products | Product Spotlight | Acne Care | Non-Surgical Facelift

email karen@skincarebykaren.com