Dermal Diagnosis Form
Date of Birth
Please enter a valid phone number.
Street Address Line 2
State / Province
Postal / Zip Code
You would characterize your facial skin as:
How many large pores do you have?
A few in the T-zone
In photos, your face looks shinny?
If you don’t use anything, your facial skin:
Feels very dry or cracks
Looks shiny, or I never feel that I need a moisturizer
Please enter any other details you feel about your skin's dry or oilyness
Have you been diagnosed or have any semptoms listed below?
Acne and rosacea
Light or dark brown or grey patches
Family history of melanoma
Which ones listed below that your skin has
Blackheads and pimples/acne breakouts
Red skin, visible small red veins with/without bumps
Aging and/or pigmentation
If your skin has a tendency to develop pimples, redness, flushing, and itching, please select the ones that describes you the best.
I get red bumps on my face easily
Skin care products make my face break out, rash, itch and sting.
I get rash when I wear jewelry that is not 14-carat gold.
Sunscreens make my skin itch, burn, breakout or red
Fragranced bubble bath, massage oil, or body lotions make my skin break out, itch, or feel dry.
May face get red after exercise, with stress, strong emotion or anger.
After drinking alcohol, I tend to flush
After eating spicy, hot foods or beverages, I get red.
I look red in the photos.
I am asked if I am sunburned, even when I am not.
If your skin has a dark spots, please select the ones that describes you the best.
I have many dark spots.
I develop many dark spots on my face when I am pregnant, or on birth control pills
I have dark spots on the areas of sun exposure.
When I have a pimple or ingrown hair, I got dark spot.
Please select the ones that describes you the best.
I eat fruits.
I smoke cigarettes.
I allow my skin to tan through sports or other activities.
I engaged in seasonal tanning
Your facial wrinkles
Are present even if I'm not smiling, frowning, or lifting my brows
Visible with movement and a few at rest without movement
Only visible when I move, such as smiling, frowning or lifting my eyebrows
I don't have any facial wrinkles
Please answer how the facial skin looks like for the people listed below
At least 10 years younger
Little bit younger
Little bit older
At least 5 years older
Please upload a clear facial picture and any related documents
Drag and drop files here
Choose a file
Should be Empty: