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