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Name *

First Name

Last Name

Phone

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How would you describe your skin type? *

A) Dry: Often feels tight and can be flaky

B) Oily: Gets shiny, especially on the T-zone (forehead, nose, chin)

C) Combination: Oily in some areas (like T-zone) and dry in others

D) Normal: Rarely feels too oily or too dry

Do you experience sensitivity in your skin? (Redness, irritation, or reactions to products) *

A) Yes, frequently

B) Occasionally

C) Rarely

D) Never

What are your top skin concerns? (Select up to 3) *

A) Acne or breakouts

B) Dark spots or uneven skin tone

C) Fine lines and wrinkles

D) Redness or irritation

E) Dullness or lack of radiance

F) Dryness or dehydration

How often do you get breakouts? *

A) Regularly (multiple times a month)

B) Occasionally (once or twice a month)

C) Rarely (a few times a year)

D) Almost never

What is your daily skincare routine like? *

A) Minimal (I just wash my face)

B) Basic (Cleanser, moisturizer, SPF)

C) Moderate (Cleanser, serum, moisturizer, SPF)

D) Advanced (Complete routine with treatments, masks, etc.)

How much time do you spend outdoors? *

A) Rarely (mostly indoors)

B) A moderate amount (an hour or two daily)

C) Frequently (several hours a day)

D) Very often (outdoor job or activities)

What kind of environment are you usually in? *

A) Cold or dry (air conditioning, heaters, or cold weather)

B) Humid or hot (tropical climate or high humidity indoors)

C) Urban (exposed to pollution)

D) Varied (mix of different environments)

How well do you sleep, on average? *

A) Poorly (less than 5 hours)

B) Fair (5-6 hours)

C) Good (7-8 hours)

D) Excellent (8+ hours)

Do you drink enough water daily? *

A) Rarely

B) Sometimes

C) Often

D) Always

What would you like to achieve with your skincare routine? *

A) Clear up acne/breakouts

B) Reduce signs of aging (wrinkles, fine lines)

C) Even skin tone and reduce pigmentation

D) Keep skin hydrated and healthy

E) Soothe sensitivity and redness

F) Add radiance and glow