On-line Skin Health Analysis

 Feeling like you don't know where to start? You've come to the right place. Our simple skin care evaluation can help you determine your skin type and its particular treatment needs. Simply answer the following questions and we will guide you to the SkinUSA products that fit your skin and your lifestyle.

When choosing a skin care program, there's much to consider. What kind of skin do you have? How often are you in the sun? What bothers you the most with your skin? 

 The purpose of this exercise is to ask you to think about the type of skin you have and how you are currently caring for it, and second, to give us an opportunity to offer you some feedback!

Whether you are just looking for guidance on general skin care or have some specific concerns about your skin, we would be pleased to share our thoughts and suggestions with you. We strongly recommend that you read our FAQ and our skin health program.

Personal Information
Name:
Address:
City:
State: *ZIP:
Country  
*Email:

Daytime Phone:

Evening Phone:

Time of the day you prefer that we call

Occupation:
Life-Style
2. Where did you find out about SkinUSA?
 
My Doctor Another SkinUSA customer
My Cosmetologist TV
Seminar Yellow Pages
Yahoo Newspaper
excite Magazine
Naseej Direct Postal Mail
Ayna Direct E-Mail
Altavista Radio advertisement
Other Search Engine
     (please specify below)
 Link from other website    (please specify below)
Skin Assessment Questionnaire
*I am: Female Male
My age range is   18-30 31-49 50+
*3. I smoke or have smoked within the last 5 years:
No         Yes     if yes, how many cigarettes/day:
*4. My "Fitzpatrick" skin type is:

Very fair skin, I never tan, I burn

Light skin, I may tan, but I usually burn

Light/medium complexion sometimes I tan, sometimes I burn

Medium complexion I usually tan, rarely burn

Dark complexion - I never burn (Hispanic, Asian, Saudi/Gulf )

African , I never burn
*5. I would describe my skin type as:

Dry/sensitive

oily

combination (T-zone)
6. I am allergic or sensitive to:
Hydroquinones: Yes No
*Alpha or Beta Hydroxy Acids: Yes No
Retin A: Yes No
Other (specify)
7.Have you been on Accutane or Roaccutane within the past 12 months?
Yes No

Do you have fine veins and broken vessels? (Telangiectasia)
Yes   No
Do you have:
Sagging skin  Firm skin

11. Have you ever had a peel? 
Yes No   if yes what kind?:

Describe your results: 

 Good results  Average results  Poor results 

13. Have you ever had laser resurfacing?
yes no if Yes when?:

Describe your results: 

 Good results  Average results  Poor results 
24. Do you develop cold sores/fever blisters?
yes no
If so, when was your last breakout?
8. I am using the following products as part of my skin care routine:
 
Soap
Moisturizer
Cleanser
Toner
Lightening/bleaching agent
Sun block
Tanning agent
Hypoallergenic make-up
Retin-A or Renova
Antiwrinkle
Facial masque
  I experience side effects:
yes no

If yes, explain:

*9. I would like some ideas on how to manage the following skin related concerns:
 
Preventive maintenance how to avoid premature aging of healthy skin
Persistent acne, such as "teenage" (oily skin) adult
deep cystic acne
Dark pigmentation spots
Mask of Pregnancy
Large pores
Facial wrinkles and fine lines
Sun damage such as skin roughness spotting
Acne scars
Freckles
Eyes: fine lines & wrinkles puffiness Dark circles
Scalp treatment for hair loss
10. I am using or have used skin care products from the following brands:
 
Clinique
Neostrata
BioMedic
Cellex-C
Dermalogica
Exuviance
Gly Derm
Gly-Med Plus
SkinUSA
Kinerase
M.D. Forte
Jan Marini
Obagi
Philosophy
Physician's Choice
Neutrogena
Roc/Dermatologic
SkinCeuticals
MD Formulation
Z.Bigatti
Other
I am not using any products
Other information that you think we should know about: