Yoga-360 Studio & Spa

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skin assessment.
Please answer the following questions so that there will be a better understanding of your current skin condition, general health and lifestyle, thereby allowing for better assessment and analysis of your skin care needs.
First Name
Last Name
Address Line 1
City
State
Zip Code
Daytime Phone() -
E-mail Address
What is your age?
Are you female or male?
Have you ever experienced a facial before?
If yes, how often do you get them?
Have you had laser resurfacing or reconstructive surgery on your face in the last 3 months?
Have you had injectables (botox, Restylane) in the last 3 months?
Have you used Retin-A or Accutane in the last 3 months?
Do you have any irritation, sensitivities or allergic reactions to any skin care ingredient?
If yes, what?
Do you smoke?
Do you currently use cleanser? (Brand)
Do you currently use toner? (Brand)
Do you currently use an exfoliant? (Brand)
Do you currently us a mask? (Brand)
Do you currently use serum? (Brand)
Do you currently use moisturizer? (Brand)
Are you currently using SPF? (Brand)
Are you currently using eye cream? (Brand)
Are you currently using lip balm? (Brand)
How would you classify your skin type: dry, normal to dry, normal, normal to oily, or oily?
How concerned are you with sun damage? (1- very concerned through 5-not concerned at all)
How concerned are you with uneven skin tone? (1-5)
How concerned are you with wrinkles and fine lines? (1-5)
How concerned are you with loss of elasticity? (1-5)
How concerned are you with redness? (1-5)
How concerned are you with dilated capillaries? (1-5)
How concerned are you with sensitivity/irritation? (1-5)
How concerned are you with Rosacea? (1-5)
How concerned are you with dehydration/dryness? (1-5)
How concerned are you with blackheads? (1-5)
How concerned are you with breakouts/acne? (1-5)
How concerned are you with hormonal breakouts? (1-5)
How concerned are you with large pores? (1-5)
How concerned are you with dark circles/eye area puffiness/fine lines? (1-5)
How concerned are you with chapped lips? (1-5)
How committed are you to addressing your concerns either through home care products or facial treatments? (1-5)
How willing are you to purchase home care products if it will make a positive difference in the health of your skin? (1-5)
How would you like to be contacted? (phone or email)
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Yoga-360, Inc., 91 Bankview Drive, Frankfort, IL 60423 815.806.0360