Dermal Diagnosis Form
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Male
Female
Other
You would characterize your facial skin as:
Dry
Normal
Oily
Combination
Other
How many large pores do you have?
None
A few in the T-zone
Many
Tons
In photos, your face looks shinny?
Yes
No
Sometimes
Other
If you don’t use anything, your facial skin:
Feels very dry or cracks
Feels tight
Feels normal
Looks shiny, or I never feel that I need a moisturizer
Other
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
Atopic dermatitis
Eczema
Contact dermatitis
Astma
Melasma
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
Sensitive skin
Aging and/or pigmentation
Acne
If your skin has a tendency to develop pimples, redness, flushing, and itching, please select the ones that describes you the best.
Never
Rarely
Sometimes
Often
Always
Not Applicable
I get red bumps on my face easily
1
2
3
4
5
6
Skin care products make my face break out, rash, itch and sting.
7
8
9
10
11
12
I get rash when I wear jewelry that is not 14-carat gold.
13
14
15
16
17
18
Sunscreens make my skin itch, burn, breakout or red
19
20
21
22
23
24
Fragranced bubble bath, massage oil, or body lotions make my skin break out, itch, or feel dry.
25
26
27
28
29
30
May face get red after exercise, with stress, strong emotion or anger.
31
32
33
34
35
36
After drinking alcohol, I tend to flush
37
38
39
40
41
42
After eating spicy, hot foods or beverages, I get red.
43
44
45
46
47
48
I look red in the photos.
49
50
51
52
53
54
I am asked if I am sunburned, even when I am not.
55
56
57
58
59
60
If your skin has a dark spots, please select the ones that describes you the best.
Never
Rarely
Sometimes
Often
Always
Not Applicable
I have many dark spots.
61
62
63
64
65
66
I develop many dark spots on my face when I am pregnant, or on birth control pills
67
68
69
70
71
72
I have dark spots on the areas of sun exposure.
73
74
75
76
77
78
When I have a pimple or ingrown hair, I got dark spot.
79
80
81
82
83
84
85
Please select the ones that describes you the best.
Never
Rarely
Sometimes
Often
Always
Not Applicable
I eat fruits.
86
87
88
89
90
91
I smoke cigarettes.
92
93
94
95
96
97
I allow my skin to tan through sports or other activities.
98
99
100
101
102
103
I engaged in seasonal tanning
104
105
106
107
108
109
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
Other
Please answer how the facial skin looks like for the people listed below
At least 10 years younger
Little bit younger
Exact age
Little bit older
At least 5 years older
Not Applicable
Your Mother
110
111
112
113
114
115
Your Father
116
117
118
119
120
121
You
122
123
124
125
126
127
Please upload a clear facial picture and any related documents
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