Jacqueline Grace    
Naturally Therapeutic  Skin Care & Massage             Inside Pilates Aligned
                                            Book Online 303-903-4936                         1110 Acoma Street Denver CO

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Online Facial Assessment   A Free Service for Customized Product Selection                

Let Our Lisenced Esthetician  Analyse Your Skin!    
The results of this online assessment will help you understand exactly what you need to correct and improve your skin condition. Our esthetician will review your answers personally, then provide you with product recommendations specifically designed to dramatically improve your skin care concerns. 

Please allow 48 hours or less for our lisenced esthetician to review your information and recommend products suited to your skin condion and personal lifestyle. 

Privacy Statement: The information you provide is completely confidential and used only for analysis.

It is very IMPORTANT to  answer each question on this form  before we can accept it. Please enter in YOUR EMAIL ADDRESS or we can not respond to your answers.

Your Full Name: 
Street Address:  

City:  
State & Zip:  
Contact Phone:  
Email Address:  
1. The Basics
Your Sex is: *
Your Nationality is: Asian Hispanic  CaucasianAfrican American  *
2. Facial Surgery all answers required
  1. Have you had laser resurfacing or facial Plastic Surgery in the past 3 months?
  2. Are you planning to have facial resurfacing soon?
  3. Are you planning to have eyelid surgery soon?
  4. Are you planning to have other facial Plastic Surgery soon?
Lifestyle
  1. Do you smoke?
  2. Do you have allergies to any of the following? (Check all that apply, Select at least one)







  3. Do you currently take any supplements?
  4. If you are taking supplements, which ones?    
  5. Do you use Retin-A?
    If yes:
    What do you use it for? Do you have irritation, sensitivity, flaking from Retin A use?
  6. Are you now using the Acne drug Accutane?
    If no , have you used Accutane in the past?
  7. Are you currently on a restricted diet?  
  8. Do you exercise regularly?
  9. What water temperature do you cleanse with?
    1. Do you have any special skin problems? (Check any that apply, select at least one)
      A
      A
      D
      O
      D
      L
      C
      H

      S
      E
      N
    2. Are you susceptible to cold sores?  
Your Current Skin Products

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

    1. Are you currently using bar soap to cleanse your face? No  Do you use any skin care products which contain mineral oil, lanolin, alcohol, color, fragrance, or formaldehyde?
    2. What type of skin do you have? (Check one.)

  1. Have you ever used glycolic acid?
  2. Have you ever used salicytic acid?
     
Women Only
     15.Are you taking oral contraception?
  1. Are you pregnant, trying to become pregnant, or breast feeding?

 

Men Only
         16.  Do you ever experience irritation from shaving?
  1. Do you experience ingrown hairs?
Oil Secretion
  1. What time of day do you first notice oil?






  2. Do you experience skin break-outs?
Moisture Hydration
  1. How much pure water do you consume daily? (Select one)

      
  2. When you are in the sun for extended periods, do you use a sunscreen/sunblock?
     
Capillary Activity
  1. Do you have a tendency to redness in skin tone?
     
Skin Type
  1. Which of the following most closely describes your skin type? (Select one)





Skin Quality

Please tell us about the following qualities of your skin:

  1. Facial Lines:

  2. Do you have eye area puffiness? ( )
    no
  3. Do you have dark under eye shadows?
  4. Your skin texture is:
  5. Do you have blackheads?
  6. Do you have small, red broken capillaries that show through your foundation?
     
    1. Does your skin have dry patches?
    2. Is your skin extremely dry?
  7. Your skin pore size:
  8. Your skin thickness:  
  9. Do you wear glasses?
Almost Done!
  1. Please choose up to three skin care issues that you would like help with. ( Select at least 1)






    Stimulate Collagen Production







  2.  
  3. In summary,


  4. 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? 

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.

  

Thank you for spending the time to give us accurate answers. Please send your Skin Analysis Questionaire by pressing the submit button above. You can expect a response from us in 48 hours or less.

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