Skin Care Analysis for Women

Fill out this form and Submit it now or Print the form and Fax it 415-898-3307 to Loulas. All information is confidential.

Loulas Skin Analysis

Name: Date of Birth: Occupation:
Address: e-mail:
Home Phone: Work Phone: Cell Phone:

Age Group: 14-19 20-34 35-55 55+

Background Health Information

1. How do you wash your face? Soap Cleanser
2. If Soap, what brand? If cleanser, what brand
3. Do you use moisturizer? Yes No
4. Do you use Glycolic Acid on a regular basis? Yes No
5. Are you/have you used Retina A? Yes No
6. Are you/have you taken Acculane? Yes No
7. Are you presently taking any medication? Yes No
8. Do you ever have burning/itching on your skin? Yes No
9. Are you allergic to anything? Yes No
10. Do you experience redness/irritation often? Yes No
11. Do you have heart trouble? Yes No
12. Are you diabetic? Yes No
13. Are you claustrophobic? Yes No
14. Are you on a special diet? Yes No If yes, please specify
15. Do you consume water daily? Yes No If yes, please specify
16. Do you drink coffee, tea or soda daily? Yes No Coffee ozs Tea ozs Soda ozs
17. Do you exercise? Yes No
18. Have you ever had a facial? Yes No If yes, please specify
19. Do you give yourself facials at home? Yes No If yes, please specify
20. Please list cosmetics you are now using

Skin Type Information

1. Skin Texture? Thin thick Medium
2. Complexion Color? Pale Pink Olive Sallow Suntanned Other
3. Pigmentation? Even Uneven Birthmarks Heavy Freckling Some Freckling Pregnancy Mask
4. Muscle Tone? Good Fair Fallen
5. Facial Wrinkles? Deep Wrinkling Crow's Feet Fine Lines
6. Broken Capillaries? Nose Area Cheek Area Chin Area Nose Forehead Entire Face
7. Condition Pimples? Whiteheads Flakiness Acne Scars
8. Your Skin Type Oily Combination Dry Problem Acne Couperose

Additional feedback or questions: (your concerns or expectations)

Thanks for your input