Personal Skin Analysis from Skin Care by Vanities

Complimentary
Personal
Skin Care Analysis

Submit your Personal Skin Analysis form and we'll reply with recommendations for products and treatments
to erase the mark of time & preserve that youthful glow.... Our complimentary personal skin analysis
will help you ascertain which products can best address the particular issues concerning the health of your beautiful skin!

Find the best products and advice for your individual needs!

We successfully treat adult acne, rosacea, whiteheads, blackheads, pimples, zits, scarring, sebaceous glands, cysts, and acne vulgaris with our skin care products.

Use the form below for a FREE personal skin care analysis done by a licensed, para-medically trained esthetician. The results will help you understand exactly what you need to overcome your skin-related problems. You will receive an evaluation and product recommendations specifically designed for you. This is NOT an auto-responder, but customized skin care and skin care products recommended for you and your specific needs. Each analysis requires at least 10 minutes of study time prior to recommending the skin care products prescription.

We understand how difficult it is to choose the right products. The skin care analysis will help you make informed decisions about how to handle your home skin care. Please make sure that you give an answer to every question on the form below, all answers are required so that we can perform a complete evaluation of your skin.

Privacy Statement: The information you provide is completely confidential and used only for analysis.

Name:
Address:
City: State: Zip:
We need your E-mail address to know where to send your analysis: E-mail:
Phone:
How did you find our website? If other, please enter here:

THE BASICS 1. Your Age is: Your Sex is: Female Male
FACIAL SURGERY
2. a. Have you had laser resurfacing or facial plastic surgery in the past 3 months? yes no b. Are you planning to have facial resurfacing soon? yes no c. Are you planning to have eyelid surgery soon? yes no d. Are you planning to have other facial plastic surgery soon? yes no
LIFESTYLE
3. Do you smoke? yes no
4. Do you have allergies to any of the following? (Check all that apply.) Aspirin Talc Clindamycin Retin-A Hydroquinone Alpha-Hydroxy Acids Beta-Hydroxyacids Fragrances Hydrogen Peroxide No allergies to any of the above XXX
5. Do you currently take any antioxidant supplements? yes no
6. Do you use Retin-A? yes no If yes: What do you use it for? acne fine lines
Do you have redness, irritation, sensitivity or flaking from Retin A use? yes no
7. Are you now using the acne drug Accutane? yes no If no , have you used Accutane in the past? yes no If you used it in the past, how long ago?
8. Are you currently on a restricted diet? yes no
9. Do you exercise regularly? yes no
10. What water temperature do you cleanse with? cool warm hot
11.a. Do you have any special skin problems? (Check any that apply.) I have adolescent acne eruptions I have adult onset acne I have deep cystic acne I have oily skin, but no eruptions I have dry skin with acne outbreaks I have lines and wrinkles from sun damage (photo-aging) I have combination skin, dry in some places, oily in the T- zone I have hyper-pigmentation (brown spots from sun or acne) I have acne scarring I have smooth, normal skin I have enlarged pores I have no special skin problems b. Are you susceptible to cold sores? Yes No
YOUR CURRENT SKIN PRODUCTS:
Please answer these questions about your current skin care products: 12.a. What types of cleansers are you now using? soap cleanser lotion cream b. Are you currently using bar soap to cleanse your face? Yes No 13. Do you use any skin care products which contain mineral oil, lanolin, alcohol, color, fragrance, or formaldehyde? Yes No 14.a. What type of skin do you have? (Check one.) Dry Normal to Dry Normal Normal to Oily Oily Problem/Blemished b. What product line are you currently using? c. Have you used glycolic acid? yes no don't know d. If you've used glycolic acid, what percentage?
WOMEN ONLY :
	15. Are you taking oral contraception? yes no
	16. Are you pregnant, trying to become pregnant, or breast feeding? yes no
MEN ONLY :
	17. Do you ever experience irritation from shaving? yes no
	18. Do you experience ingrown hairs? yes no
OIL SECRETION :
19. What time of day do you first notice oil? 15 to 30 minutes after cleansing Mid-morning 9 to 10 am Lunch time 12 pm Mid-afternoon 2 to 3 pm Late day 4 to 5 pm Totally dry I do not experience breakthrough oily shine during the day
20. Do you experience skin break-outs? yes no
MOISTURE and HYDRATION :
21. How much plain water do you consume daily? 1-2 cups 3-4 cups 5-6 cups 7+ cups
22. When you are in the sun for extended periods, do you use a sunscreen/sunblock? yes no
CAPILLARY ACTIVITY :
23. Do you have a tendency to redness in skin tone? yes no
SKIN TYPE :
24. Which of the following most closely describes your skin type? Very fair skin tone, blond or redhead, freckles, burns easily, never tans. Light skin tone, will tan, but usually burns. Light to olive skin tone, sometimes burns, hazel eyes, auburn to light brown hair. Medium brown skin tone, rarely burns. Dark brown skin tone, very rarely burns, dark eyes, dark hair. Dark skin tone, burn resistant, dark eyes.
SKIN QUALITY:
Please tell us about the following qualities of your skin: 25 . Facial lines: a few or none some around the eyes around the eyes and on the face around the lip area 26 . Do you have eye area puffiness? no occasionally frequently 27. Do you have dark under eye shadows? seldom occasionally frequently 28. Your skin texture is: bumpy and uneven smooth and soft coarse and grainy 29. Do you have blackheads? few or none some, especially in the T-zone problem 30 . Do you have patches of small, red, broken capillaries? problem (nose/cheeks/chin) a few none 31.a. Does your skin have dry patches? never occasionally frequently b. Is your skin extremely dry? Yes No 32. Your skin pore size: enlarged all over some enlarged in the T-zone nearly invisible 33. Your skin thickness: very thick normal very thin 34. Do you wear glasses? yes no
35. What results are you looking for? Clear up acne eruptions Clear up blackheads Minimize size of pores Decrease oiliness of skin Diminish the appearance of capillaries on the face Lighten skin complexion or hyper-pigmentation areas Restore skin elasticity Hydrate the skin Smooth skin texture Diminish flakiness of skin Lighten acne scarring Diminish wrinkles and fine lines Pre-facial surgery skin preparation Post-facial surgery skin care No special results, just the best regimen for my skin
36. Briefly, is there anything else about your FACIAL skin that was not addressed by the questions above: (Note: Sorry, we cannot address other medical problems.)
38. In summary, What do you like BEST about your facial skin? What do you like LEAST about your facial skin?
39. Are you interested in receiving our Free monthly E-Zine, skin care News, containing Vanities news, free articles and information on our specials? Yes, I would like to subscribe to your free monthly e-zine.
BY SUBMITTING THIS FORM, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE FOLLOWING: This questionnaire submitted online cannot substitute for the completeness of an in-person consultation with a licensed, professional skin care esthetician or doctor. The estheticians of Vanities® Skin Care & Makeup analyze your skin type and suggest products solely on the completeness and accuracy of the information provided by you. Any products purchased by you, in response to SkinCarebyVanities®.com are suggestions based on information you have provided in this form, are your responsibility and cannot be returned to SkinCarebyVanities®.com.

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At Vanities Skin Care
we offer the knowledge and expertise to help both men and women choose
which products are appropriate for the health of your skin.

Karen Laine owner
phone & fax 512.847.8052
KLaine@SkinCarebyVanities.com

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