Skin Assessment
TOP SKIN CONCERNS
What are your key concerns? (Check all that apply)
Fine lines and wrinkles
Excess oil or blemishes
Large pores
Uneven texture or visible discoloration
Dry patches and sensitivity
Dark circles
Visible redness
Sun damage
CURRENT ROUTINE
What is your current skincare routine? (Check all that apply)
Cleanser
Toner
Prescribed topicals
Vitamin C
Sunscreen
Exfoliation
Serum
Retinol
Facial oil
Moisturizer
MAKEUP
Do you wear makeup on a daily basis?
Yes No
DAILY SUN EXPOSURE
What is your daily sun exposure?
Less than 15 minutes
1–2 hours
2+ hours
CLIENT INFORMATION
Name
Phone
SKIN CHARACTERISTICS
(Check all that apply)
Age
Blemishes (mild, moderate, extreme, please specify below)
Oily (excess sebum can make skin appear shiny and feel greasy, especially in the T-zone: forehead, nose, and chin)
Dry (skin looks and feels rough, itchy, flaky scaly, or prone to sensitivity)
Combination (has both oily and dry areas on the face)
Texture (skin feels rough, bumpy, or uneven)
Discoloration (color, texture, or pigmentation that differs from your natural skin tone)
Sensitive (stinging, burning, itching, pain, or tingling)
Wrinkles
STRESS LEVEL
Low
Medium
High
VITAMIN ROUTINE
Are you currently taking any vitamins or supplements?
Yes No
List of current supplements
SLEEP
4–5 hours
5–6 hours
7+ hours
WATER INTAKE
Less than 8 glasses
About 8 glasses
8+ glasses