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Online Consultation

Please answer the following questions regarding your current skin condition, overall health and lifestyle. We will provide you with a customized skin analysis and product recommendations for your skin care needs.

Items marked with an * are required fields.

Name:*

Email:*

Phone:*

Age:*

Male * Female *

For added security type the characters you see in the picture into the field below

*

Please check if presently using any of the following.:

Retin A/Renova	Topical Vitamin C
Glycolic Acid/Alpha Hydroxy Acid	Hydroquinone
Accutane

Have you had any of the following?

Recent Surgery	Keloid Scarring
Cosmetic Surgery	Laser Resurfacing
Injectables	Chemical Peels
Skin Cancer	Hepatitis
Dermatitis	Other. Please specify:

Which conditions do you want to improve?

Hyper pigmentation (Brown Spots)	Sun Damage
Acne	Enlarged Pores
Acne Scarring	Fine Lines & Wrinkles

Have you ever had an allergic reaction to any skin care product or cosmetic?

Yes No

If "Yes", please specify the product(s):

Ethnic Background:

Caucasian	African American
Hispanic	Native American
Asian	Other. Please specify:

Skin Type:

Oily	Dry
Combination	Normal

Specific Skin Problems

Sensitive	Broken Capillaries
Reddens easily	Oily
Rosacea	Enlarged Pores
Brown Spots	Fine Lines
Acne	Itchiness
Excessive Dryness	Wrinkles
Eczema	Psoriasis
In-grown hairs

Are you using any skin lighteners?

Yes No

Areas of Hyper-pigmentation:

Type Of Sun Protection

Clothes	Sun Glasses
Hat	Sun Block

Do you sunbathe, use tanning beds or participate in outdoor activities?

Yes No

Skin Texture

Coarse	Smooth
Thin Transparent	Thick, Pebbly

Acne Conditions

Pustules	Cysts
Nodules	Comedones
Papules	Milia

Are you using or have ever used any medications for acne?
If so, please name the medication:

Have you seen a Dermatologist in the past year?

Yes No

What medications do you take on a regular basis?

Do you take recreational drugs?

Yes No

Skin Irregularities

Razor Bumps	Heavily Congested
Excessive Dryness	Enlarged Pores
Excessive Oiliness	Blackheads/Whiteheads
Impurities

Any Other Skin Irregularities?

Have you ever had Herpes (cold sores)?

Yes No

Have you ever been treated with Zovirax or any medication for Herpes?

Yes No

Do you have diabetes?

Yes No

Are you presently under a physicians care for any reason?
Explain:

Are you allergic to aspirin?

Yes No

Do you have any other allergies?

Yes No

If yes, please list:

Do you smoke?

Yes No

Do you take nutritional supplements?

Yes No

Are you on a diet?

Yes No

Do you exercise?

Yes No

Are you currently having any facial treatments done?

Yes No

How is your general health?

Excellent Good Fair Poor

What skin care products are you currently using? *

What is it about your skin you would like to change?

Female Clients Only:

Are you on hormone replacement therapy?

Yes No

Are you presently taking birth control pills?

Yes No

Are you pregnant or planning to be?

Yes No

Disclaimer: Answering these questions provides information that will act as a general guide to suggest possible use of home care skin products and possible referral for professional treatments. In no way is Esente Physioceuticals able to diagnose, treat, or prescribe for specific skin conditions.