1) FOREHEAD AREA

Dehydration
Dryness
Sensitivity
Blotchy Complexion
Oily Complexion
Visible Pores
Active Acne
Congestion (Clogged Pores)
Dullness
Pigmentation (Age Spots)

2) EYE CONTOUR AREA

Dehydration
Dryness
Sensitivity
Dullness
Pigmentation
Dark Circles
Puffiness
Crow's Feet
Under-Eye Wrinkles

3) NOSE AND CHEEKBONE AREA

4) NASOLABIAL, LIP AND CHIN AREA

5) FACIAL CONTOUR AREA

Dehydration
Dryness
Sensitivity
Congestion (Clogged Pores)
Dullness
Pigmentation
Lack of Firmness

6) NECK AND DOCOLLETE AREA

Neck Lines
Lack of Firmness
Under-defined Jawline
Dehydration
Hyperpigmentation
Fine Lines
Wrinkles

GENERAL HEALTH QUESTIONS:

HAVE YOU EVER BEEN TREATED WITH ANY OF THE FOLLOWING? (Check All That Apply)

Acutane
Retin A
Tretinoin
Topical Antibiotics
Cortisone
Alpha Hydroxy Acids
Hydroquinone
None of the Above
Other

DO YOU SMOKE?

Yes
No

STRESS LEVEL?

Low
Moderate
High

DO YOU EXERCISE REGULARLY?

Yes
No

SUN EXPOSURE

Low
Moderate
High

DO YOU REGULARLY USE SUNSCREEN?

Yes
No

DO YOU HAVE PSORIASIS?

Yes
No

HOW MANY GLASSES OF WATER DO YOU DRINK A DAY?

DO YOU HAVE ECZEMA?

Yes
No

ARE YOU ON ANY SPECIFIC DIET?

Yes
No

DO YOU HAVE ANY ALLERGIES?

Yes
No

ARE YOU ON ANY SPECIFIC DIET?

Yes
No

A BIT ABOUT YOU:

FIRST NAME

YOUR GENDER

Female
Male

LAST NAME

(Female Clients) ARE YOU PREGNANT?

Not Applicable
Yes
No

HORMONAL IMBALANCES?

Not Applicable
Yes
No

ARE YOU PLANNING PREGNANCY?

Not Applicable
Yes
No

YOUR AGE GROUP

Under 24
25 - 29
30 - 39
40 - 54
55 - 69
70+

WHAT ARE YOUR MAIN CONCERNS?

DESCRIBE YOUR CURRENT AT HOME SKINCARE ROUTINE:

GENERAL HEALTH QUESTIONS:

A BIT ABOUT YOU:

Thanks for getting in touch!

Thanks for getting in touch!

Dr Dennis Gross MD Skincare