Consultant Survey

Name

First NameLast Name

Email

example@example.com

Phone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date

Education

Check any interests that you like:

Any known allergies to skin / cosmetic products?

Please give details about your skin care routine

Duration

7 days14 days21 daysundecided

Skin type

Skin tone

Favorite skincare brand(s)

Do you have extremely dry skin?

yesno

Do you have lines/ wrinkles compared to peers?

yesno

Do you have uneven skin tone?

yesno

Do you have redness?

yesno

Do you use sunscreen? if yes spf?

yesno

Are there any particular ingredient you avoid in hair and skincare products? If Yes explain:

yesno

What type of hair do you have

Do you have scalp problems?

yesno

Please give details

Have you had any side effects from hair and skincare products? If yes explain:

yesno

Please give details

Please briefly describe your hair care routine

How often do you buy hair and skincare products?

What products do you use?

In a typical week how many different types of hair care and skincare products do you use(shampoo, conditioner, mousse, treatment, hair spray, grease, gel, stylers, lotions, body wash)

How do you select products?

Gender

MaleFemaleN/A

Age

Any further explanation or concerns: (please use the space below)