Skin Care Analysis
Would you like to receive Health and Skin Care infomation from the expert. Belinda's experience will give you valuable tips on a wide range of topics. And best of all it is FREE
Name:  
E-mail Address:
Fill out your Free Skin Care Analysis here.
For assistance phone toll free 1 (877) 493-5130
or
email
If you will be Faxing or Mailing your order use the

Printable (PDF) Version of the Order Form and Skin Care Analysis

Just Click on the above Link to the Order Form and/or Skin Care Analysis. The form will appear on your Screen. Print it. Fill it out.
Name
Address
City
State /Province
Country
Zip/Postal Code
eMail *required
Phone Number
Fax Number

What is your Birthdate?
 
Month:
Birth Day:
Birth Year: (Four digits for example: 1976) 

Are you pregnant?

 Yes No
   

What is your Ethnic Background?

 

Please check any health conditions which you have had or are now experiencing:

Hypoglycemia
High/Low Blood Pressure
Hepatitis
Heart Problems
Cancer
Alcoholism
Hysterectomy
Thyroid (Over)
Thyroid (Under)
Hormonal Problems
Sugar Diabetes
Metabolic Disorders
Other

Please list all medications that you take regularly. Include hormones, vitamins, etc.

Describe a typical day's diet and salt consumption.


Types and quantities of fluids consumed daily

Drink
Quantity in ounces
Water
Coffee
Teas
Juices
Colas
Other

Do you smoke?

Yes No

If Yes How Much

 

  

Have you ever had an allergic reaction to products you have applied to your skin?

 Yes No

If Yes ... What product or ingredients?

 

  

Do you have allergies?

 Yes No

If Yes What Type?

 

  

Have you ever applied pharmaceutical or prescription grade products to your skin?

Yes No

If Yes What Products or Ingredients?

Any side effects?

Yes No

If Yes please Describe.

 

  

Have you ever undergone treatment from a dermatologist?

Yes No

When?

For what type of condition?

Any negative side effects? Yes No
   
What type of climate do you live in?
How much sleep do you get per night?
How much exercise do you get per day?
Are you currently or periodically under a lot of stress? Yes No
   
What is your specific concern with your skin?
What is your level of commitment to a skin care regimen?

 

Do you consider yourself to have Dry, Normal or Oily Skin?
When looking in the mirror, can you see your pores? Yes No
   
How often do you cleanse?
What do you use to cleanse?
After cleansing does your face feel taught and dry? Yes No
   
When you wake up in the morning does your face feel ...
Taught Yes No
Dry Yes No
Perfect Yes No
Oily Yes No
   
Do you prefer the feel of a Milk or Gel based cleanser?
   
Does your skin have a rough scaly appearance and feel? Yes No
If Yes Where?
   
Do you have irritation and/or dry patches? Yes No
If Yes Where?
   
Does your skin tone have brown spots and or blotches? Yes No
If Yes Where?
   
Does your skin tone have a reddish appearance? Yes No
If Yes Where?
   
Can you visible see red veins running through your cheek area? Yes No
   
Do you have any scarring? Yes No
If Yes from What?
   
Do you have fine wrinkles? Yes No
If Yes Where?
   
Do you have deep lines? Yes No
If Yes Where?
   
Do you have acne? Yes No
Small bumps? Yes No
Small pustules? Yes No
Large pustules? Yes No
   
Do you use sunblock daily? Yes No
Do you have visible sun damage? Yes No
If Yes ...
What does it look like to you?
How does your skin react to sun exposure?
   
How much sun exposure have you incurred in your lifetime?
   
Do you use Retin A? Yes No
For what type of condition?
   
Are you currently or have you ever used Accutane? Yes No
 
   





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