Skin Health Questionnaire

The following questionnaire is not intended to be a diagnostic tool, and all information collected here is held in strict privacy and confidentiality. For more information, read our Privacy Policy.

Your Name
Your Phone
Mailing Address
Your Email Address
Gender	Female Male
Age Group	14-18 18-25 25-35 35-45 45-55 55-65 65+
How do you describe your skin?	Normal Dry Combination Oily
What are your concerns/goals regarding your skin?
Do you have any medical conditions that affect your skin? Please describe
Have you been diagnosed and treated by a health practitioner for any of the following?	Acne Eczema Impetigo Inflammatory Conditions (i.e., Lupus) Rosacea Psoriasis Fungal Infections Viral Infections (i.e., Herpes Virus/HIV)
If so, when and with what (please include any prescription medications and natural remedies)?
Are you currently treated for any of the above? Please describe
What is your skin care home regimen? List all products you are consistently using
Are you interested in non-invasive rejuvenation treatments? Please be specific
Do you have any specific questions regarding your skin health?
Are you interested in scheduling and obtaining a professional consultation/recommendation? (An office visit fee applies for this service) Yes No
Security Code	(Enter the number below)