Skin Assessment TOP SKIN CONCERNS
CLIENT INFORMATION
What are your key concerns? (Check all that apply)
Name
Age
Fine lines and wrinkles Excess oil or blemishes Large pores
Uneven texture or visible discoloration Dry patches and sensitivity Dark circles
Phone
Visible redness
SKIN CHARACTERISTICS
Sun damage
(Check all that apply)
CURRENT ROUTINE
Blemishes (mild, moderate, extreme, please specify below)
What is your current skincare routine? (Check all that apply)
Oily (excess sebum can make skin appear shiny and feel greasy, especially in the T-zone: forehead, nose, and chin)
Cleanser Toner Prescribed topicals Vitamin C
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)
Sunscreen
Discoloration (color, texture, or pigmentation that differs from your natural skin tone)
Exfoliation
Sensitive (stinging, burning, itching, pain, or tingling)
Serum
Wrinkles
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
STRESS LEVEL Low
SLEEP
Medium
4–5 hours 5–6 hours
High
7+ hours
VITAMIN ROUTINE Are you currently taking any vitamins or supplements?
No Yes List of current supplements
WATER INTAKE Less than 8 glasses About 8 glasses 8+ glasses