Skin Evaluation

Beauty has never been an exact science until now

Editorial

Your skin Evaluation
All the information is strictly confidential is not released to any source whatsoever
Our response will be emailed to you
WE will not respond to any request with incomplete information

Sex	male Female
Age
Full Name
Street Address
City
State, Zip
Country
Telephone
Email

Skin Evaluation

1- Are you pregnant or breast-feeding? Yes No

2- Do you smoke? Yes No

3- Have you undergone laser resurfacing in the last 4 months?
Yes No

4- Which of the following describe best your skin?
    Somewhat oily in T-zone but not all over
    Dry all over
    Sensitive and dry all over
    Oily
    Blemished and with problems
    Sun and environmental damage

5- Have you been diagnosed with any of the following:
    Acne or deep cystic acne
    Rosacea with dry and sensitive skin
    Keratosis Pilaris
    Eczema or Psoriasis
    Dermatitis or Folliculitis
    Ingrown hair

6- Do you have Acne breakouts?
    Never
    Occasional
    Once monthly
    Persistent

7- Are you allergic to any of the following?
    Alpha or Beta hydroxy acids
    Hydroquinone
    Benzoyl Peroxide
    Sulfur
    Others

8- Are you on any of the following medications?
    Accutane
    Retin-A or Renova
    Differin or Azelex
    Metrogel cream
    Birth control pills or Hormone replacement
    Vitamins

9- Do you have facials? Yes No
How often?

10- Do you use sun screen daily? Yes No

11- Do you exercise? Frequently Occasionally

12- How many glasses of water do you drink daily?
8 6 4 2

13- What is your level of stress?
none Low Medium High

14- What additional results are you looking for?
    Improve skin tone and texture
    Fade and remove pigmented and dark spots
    Control excess oil
    Restore skin elasticity and firmness
    Diminish wrinkles and fine lines
    Diminish eye area Puffiness and dark circles
    Minimize pores
    Clear black and white-heads
    Clear Acne and Blemishes
    Improve acne scarring
    Increase hydration and softness
    Treat ingrown hair

15- Is there anything else about your facial skin you would like to discuss?

By submitting this form I acknowledge that I have read and understood the following:
This questionnaire submitted online cannot substitute for in- person consultation with licensed aesthetician or doctors. The Specialists-team of Biomani Scientific SkinCare analyzes your skintype and suggests products based on the completeness and accuracy of the information provided by you. If you are not satisfied with any product purchased by you in response to Biomani Specialists-team, return it within two weeks of the date of purchase for full refund (less S&H).

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