Skincare Questionaire
Please answer these questions so that we may have a better understanding of your general
health and lifestyle. This will help us more accurately analyze your skin, and the possible
factors affecting your present condition.
1. Name _________________________________________________________
Address _________________________________________________________
City_____________________________________________________________
State______________________ Zip_______________________
Home Phone _________________________________ Birth date __________________________
Business Phone ______________________________ Age _______________________________
Email ________________________________________
2. Have you ever had an allergic reaction to products you’ve applied to your skin?
Yes No
If so, what products? _____________________________________________________________________
3. How often do you cleanse? Once a day Twice More
4. What products do you use?
Cleansers Toners Scrubs Masks Moisturizer
Sunscreen SPF 2 4 6 8 15+
Are you sensitive to PABA? Yes No
5. Are you using Retin A? Yes No Accutane? Yes No
6. What is your specific concern with your skin?
Dehydration Blackheads
Excessive oil Whiteheads
Looking old Millia
Irregular Pigmentation Acne
Visible Capillaries Sensitivities
Wrinkles Lines
7. Have you received corrective skin care treatments before? Yes No
8. How did you hear of Tierny Tassler Skincare?
Friend Relative Advertisement Other______________________
9. Please check any health conditions which you have and or are now experiencing
Hypoglycemia Pregnancy
Heart problems High / Low Blood pressure
Hysterectomy Silicon or Zyderm injections
Sugar Diabetes Thyroid (over / under)
Alcoholism Metabolic Disorders
Hepatitis Hormonal problems
Cancer Other
10. What is your ethnic background? ________________________________________________________
11. Please list all the medications that you take regularly. Include hormones, vitamins, etc.
____________________________________________________________________________
____________________________________________________________________________
12. Do you have any metal implants in you body other than dental fillings (such as pacemakers, pins in bones
or copper IUD)? Yes No
13. Have you every undergone treatment from a dermatologist? Yes No
When?________________________ For what condition?________________________________
Were there any negative side effects?__________________________________________
14. Have you undergone plastic surgery on your body __________________________________
Chemical Peel? Yes No Dermabrasion? Yes No
15. Is your diet balanced? Mostly Sometimes Never
Salt consumptions High Low Restricted
16. Do you smoke? Yes No
17. Do you have a physically active lifestyle?
Extreme exertion Moderate Sedentary
18. Sleeping habits 8 hours less than 8 hours
19. Are you currently experiencing excessive or abnormal stress levels? Yes No
20. Is there a history of acne in your family? Yes No
21. How much water do you drink per day? 8 glasses or more Less than 8 glasses
22. Other fluid consumption
Coffee Caffeinated Tea Colas Juice Alcohol
23. How much sun exposure do you get per day? Before 10 AM or after 3 PM Between 10 AM to 3 PM
24. Do you use tanning booths? Yes No
