Funke Roberts-Quadri
The Ageless Skin Expert
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SKIN QUESTIONNAIRE
What are your concerns?(Check All That Apply) Acne and Blemishes Dehydration (Feels Tight) Referral Oiliness Dryness (Feels Tight and is Flaky) Brown / Sun Spots Fine Lines Deep Wrinkles Broken Capillaries Easily Irritated by Products Loose Skin Clogged Pores Large Pores Blackheads Age Prevention Loss of Tone / Lack of Firmness Keeping Skin Healthy Uneven Skin ToneRedness / Sensitivity Others
Do you have any Issues?(Check All That Apply) Under Eye Puffiness Broken Capillaries Dark Circles Post – Breakout Marks Milia (Hard White bumps on the skin commonly found around the eyes) Others
How Oily or Dry is your Skin? Oily year round Normal year round Combination year round Combination in the summer/sunny season Oily in the summer/sunny season combination in the winter/rainy season Dry year round Normal in the winter/rainy season Combination (T-zone oil) Oily Year round Normal in the summer, dry in the the winter/rainy season
How often do you get blemishes? Never (this is not an issue for me) Occasionally (a few a month) Daily (a new blemish appears every day Rarely (once in a while) Occasionally (once a month or less) Often (approximately 2-3 breakouts week)
What type of blemishes do you get most often?(Check all that apply)
Cysts (hard, sore “underground” blemishes under the skin that rarely surface) Pustules (red, inflamed, traditional “zits” that usually surface) Whiteheads/Closed Comedones (non-sore, clogged bumps under the skin) Others
Where do you get the majority of your blemishes? Forehead Cheeks Chin/Jaw Line/Neck Nose Back Others
Can you summarize your skin care concerns