CONFIDENTIAL SKIN HEALTH QUESTIONNAIRE

HAVE YOU BEEN TREATED FOR: (PLEASE CHECK)

WHEN YOU GO OUT IN THE SUN, DO YOU (PLEASE CHECK):

HAVE YOU BEEN UNDER THE TREATMENT PLAN OF A:

ARE YOU CONCERNED ABOUT SKIN CONDITIONS ON YOU BODY? (CHECK ALL THAT APPLY)

YOUR SKIN TYPE IS? (PLEASE CHECK ONLY ONE)

IN ORDER OF IMPORTANCE, PLEASE RANK 1 (MOST IMPORTANT) TO 5 (LEAST IMPORTANT):

THANK YOU FOR COMPLETING THIS CONFIDENTIAL QUESTIONNAIRE.

THIS INFORMATION WILL ALLOW YOUR PROFESSIONAL SKIN CARE SPECIALIST TO PROVIDE THE OPTIMUM IMAGE PRODUCTS AND SERVICES.