Vonetta Cosmetics Skin Analysis Questionnaire

Name*

First NameLast Name

E-mail*

Birth Date*

MonthDayYear

City*

State*

How did you hear about us?*

If Others, please specify?

1. Please list any chronic health problems which you have/have had:*

2. Please list all medications you take or use regularly.*

3. Are you pregnant?*

4. Do you have permanent face make up?*

5. Of the foods listed below, can you pick some of your favorites?*

6. Do you drink coffee, tea or alcohol?*

CoffeeTeaAlcoholN/A

7. How many cups of water do you drink per day?

8. Are you allergic to any of these ingredients?*

9. Do you have any seasonal or environmental (grass, pet danders, pine tree...etc) allergies?*

GrassPet DandersN/AOther

10. If you do have an allergy listed above, do you take allergy medicine regularly to control your allergies.*

11. Do you smoke (cigarettes or recreational products)?*

How many per day?

12. Are you currently experiencing skin problems? If so what kind?*

12-a. If you are having an issue with acne are your pimples big and painful?*

12-b. Small and gritty?*

12-c. Are your breakouts worse at cycle time?*

13. Do you play sports or work out?*

14. Does your skin sting when you do your skincare routine?*

15. Please describe your skincare routine morning/evening? (Use product names)?

16. Please provide additional information if needed?

Left Side Image (no makeup please)

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Right Side Image (no makeup please)

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Front Image (no makeup please)

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Required*

A treatment with you in mind.