1. Have you had laser resurfacing or facial Plastic Surgery in the past 3 months? Yes No
2. Are you planning to have facial resurfacing soon? Yes No
3. Are you planning to have eyelid surgery soon? Yes No
4. Are you planning to have other facial Plastic Surgery soon? Yes No

3. Do you smoke? Yes No
4. Do you have allergies to any of the following? (Check all that apply, Select at least one)
   Aspirin
   Retin-A
   Hydroquinone
   Alpha Hydroxyacids
   Beta Hydroxyacids
   Fragrances
   Hydrogen Peroxide
   No allergies to any of the above
5. Do you currently take any supplements? Yes No
6. If you are taking supplements, which ones?    
7. Do you use Retin-A? Yes No
   If yes:
   What do you use it for? Acne Fine Lines  Brown Spot Removal
   Do you have irritation, sensitivity, flaking from Retin A use? Yes No
8. Are you now using the Acne drug Accutane? Yes No
   If no , have you used Accutane in the past? Yes No
   If you used it in the past, how long ago?    
9. Are you currently on a restricted diet? Yes No 
10. Do you exercise regularly? Yes No
11. What water temperature do you cleanse with? Cool Warm Hot
12. 1. Do you have any special skin problems? (Check any that apply, select at least one)
       Adolescent Acne eruptions
       Adult onset Acne
       Deep cystic Acne
       Oily skin, but no eruptions
       Dry skin with Acne outbreaks
       Lines and wrinkles from sun damage (photoaging)
       Combination skin, dry in some places, oily in the T zone
       Hyperpigmentation (brown spots from sun or Acne)
       Acne scarring
       Smooth, normal skin
       Enlarged pores
       No special skin problems
    2. Are you susceptible to cold sores? Yes No 

  12.  What types of cleansers are you now using? (Select at least one to process your facial analysis)
Soap                        Cream                    Scrub
Cleanser                    Lotion

1. Are you currently using bar soap to cleanse your face? Yes No  Do you use any skin care products which contain mineral oil, lanolin, alcohol, color, fragrance, or formaldehyde? Yes No
2. What type of skin do you have? (Check one.)
   Dry Normal to Dry
   Normal Normal to Oily Oily
12. What product line are you currently using?  
13. Have you ever used glycolic acid?
    Yes No Don't knmow
14. If you've used glycolic acid, what percentage?  
15. Have you ever used salicytic acid?
    Yes No Don't know 
16. If you've used salicytic acid, what percentage?  

15. Are you pregnant, trying to become pregnant, or breast feeding?
    Yes No

17. Do you experience ingrown hairs?
    Yes No

19. What time of day do you first notice oil?
    15 to 30 minutes after cleansing
    Midmorning 9 to 10 am
    Lunch time 12 pm
    Mid afternoon 2 to 3 pm
    Late Day 4 to 5 pm
    Totally Dry
    I do not experience breakthrough oily shine during the day
20. Do you experience skin break-outs?
    Yes No

21. How much pure water do you consume daily? (Select one)
    1-2 cups 3-4 cups
    5-6 cups 7+ cups  
22. When you are in the sun for extended periods, do you use a sunscreen/sunblock?
    Yes No 

23. Do you have a tendency to redness in skin tone?
    Yes No 

24. Which of the following most closely describes your skin type? (Select one)
    Very fair skin tone, blond or redhead, freckles, burns easily, never tans.
    Light skin tone, will tan, but usually burns.
    Light to olive skin tone, sometimes burns, hazel eyes, auburn to light brown hair.
    Medium brown skin tone, rarely burns.
    Dark brown skin tone, very rarely burns, dark eyes, dark hair.
    Dark skin tone, burn resistant, dark eyes.

Please tell us about the following qualities of your skin:

25. Facial Lines:
    a few or none around the eyes
    around the eyes and on the face around the lip area
26. Do you have eye area puffiness? ( )
    no occasionally frequently
27. Do you have dark under eye shadows?
    seldom occasionally frequently
28. Your skin texture is:
    bumpy and uneven smooth and soft coarse and grainy
29. Do you have blackheads?
    few or none some, especially in the T-zone problem
30. Do you have small, red broken capillaries that show through your foundation?
    problem (nose/cheeks/chin) a few none 
31. 1. Does your skin have dry patches?
       never occasionally frequently
    2. Is your skin extremely dry?
       Yes No
32. Your skin pore size:
    enlarged all over some enlarged in the T-zone nearly invisible
33. Your skin thickness: very thick normal very thin 
34. Do you wear glasses? yes no

35. Please choose up to three skin care issues that you would like help with. ( Select at least 1)
    Clear up Acne eruptions
    Clear up blackheads and/or whiteheads
    Minimize size of pores
    Decrease oilyness of skin
    Diminish the appearence of capillaries on the face
    Lighten skin complexion, hyperpigmentation areas or brown spots
    Restore skin elasticity 
    Stimulate Collagen Production
    Hydrate the skin
    Smooth skin texture
    Diminish flakiness of skin
    Lighten Acne scarring
    Diminish wrinkles and fine lines
    Pre-facial surgery skin preparation
    Post-facial surgery skin care
    No special results, just a healthy regimen to maintain the youth of my skin
36. I would like Jacqueline Grace Skin Skin Care to professionally choose the most effective products for my skin type.  yes no (Required before we can reccomend products for you) 
37. In summary,
    
    1. What do you like best about your skin?
       
    2. What do you like least about your skin?
       
38. Are you interested in receiving Skin'N Massage News our free monthly e-newsletter featuring useful, natural heath oriented facial and body information with  monthly featured products and specials? 
    Yes, I would like to subscribe to Skin'N Massage News!

BY SUBMITTING THIS FORM I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE FOLLOWING:
This questionnaire submitted online cannot substitute for the completeness of an in-person consultation with a licensed professional skin care esthetician. The licensed esthetician at Jacquelinegraceskin.com analyzes your skin type and suggest products soley on the completeness and accuracy of the information provided by you. Any products purchased by you in response to Jacquelinegraceskin.com are suggestions based on information you have provided in this form, are your responsiblility and cannot be returned to Jacquelinegraceskin.com.

IMPORTANT! You must provide an answer to every question on this form in order for it to be accepted.