Name: |
Email Address: |
| Do you wish to be informed of special sales via e-mail?
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| Sex:
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Age:
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How would you describe your facial skin?
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How would you describe the skin on your trunk and extremities?
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Which of the following general categories describes you?
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Allergies:
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| Have you ever been diagnosed with estrogen-dependent tumors?
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Have you undergone chemotherapy treatment or radiation therapy in the past two years?
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Do you suffer from rosacea, acne, eczema, psoriasis, or other skin conditions?
If “yes”, please list:
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Have you ever been told that you’re a hypertrophic scarrer?
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Have you ever had a wound that left an abnormally large scar?
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Do you take medication that makes you more susceptible to sunburn?
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Have you ever suffered frequent sunburns or had extensive sun exposure without the use of a sun block?
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Do you live in a moderate climate that is hot and humid during the summer?
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Do you live in a climate that is cold, dry, and windy during the winter months?
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Do you frequently engage in outdoor activities such as running, bicycling, tennis or other sports?
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Are you currently pregnant?
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What are your particular skin concerns?
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May we keep this completed questionnaire on file for future reference?
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