Skin Care Analysis for Men
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Loulas Skin Analysis for Men - "Stand out Handsome"


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


Age Group: 20-30 30-40 40-50 50-60 70+


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 skin care products you are now using
21. What is your current shaving system? Wet Electric
22. Do you ever experience irritation from shaving? Yes No
23. Do you experience ingrown hairs? Yes No


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
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
9. Do you have Acne? Yes_ No_
If Yes, how Advanced? mild_ Medium_ Advanced_
How often do you breakout_ Occassionally_ Weekly_ Monthly_
Additional feedback or questions:

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