Skin Analysis

*

First Name Last Name

Email *

example@example.com

Do you wish to recive Email Newsletters or Specials from Beautyfluff? *

Yes No

Gender *

Male Female N/A

Age

18-30 31-50 51 & Older

What are your main concerns? (check all that apply) *

Clogged Pores Blemishes Acne Scars Pigmentation Spots Sensitivity Skin Aging Dry Skin Uneven Skin Tone

How would you describe your skin tone? *

Burns Easily Burns then Tans Sometimes Burns Rarely Burns Never Burns

How would you describe your skin? *

Normal Dry Ance Oily/ Combination Sensitive

How would you describe your pores? *

Small Large Small on the cheek, large in the T-Zone

Please rate your stress level: *

Low Medium High

How much water do you drink daily? *

None 1-8 oz 16-32 oz 32 oz +

Does your face feel tight? *

Yes No

Do you have clogged pores? *

Yes No

Do you have blemishes? *

Yes No

Do you smoke? *

Yes No

Do you consume caffeine or alcohol? *

Yes No

Do you take medication? *

Yes No

Do you use tanning beds? *

Yes No

Do you use sunscreen? *

Yes No

Are you concerned with Anti-Aging? *

Yes, I want to prevent lines Yes, I have lines No

Are you concerned with any of the following? *

Under eye dark circles Eye puffiness Eye lines/ wrinkles Eye dryness None

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