You can finally discover the best products and advice for your individual needs.

Great Skin successfully treats adult Acne, Eczema, Rosacea, whiteheads, blackheads, pimples, zits, scarring, sebaceous glands, cysts, Rash and Acne vulgaris with their premium professional and physician-grade skin care products formulated for each of these specific needs.

Your personal skin care analysis is done by estheticians, under the guidance of Doctor Mark E Van Wormer, MD, ABAAM.

The results will help you understand exactly what you need to overcome your skin-related problems.

You will receive an evaluation and product recommendations specifically designed for you.

This is NOT an auto-responder, but customized skin care and skin care products prescribed for you by Doctor Van Wormer and his expert skin care therapist wife, Lori.

Each analysis requires at least 10 minutes of study time prior to recommending the skin care products prescription.

We understand how difficult it is to choose the right products, This skin care analysis will help you make informed decisions about how to handle your home skin care.

Please make sure that you give an answer to every question on the form, all answers are required so that Great Skin can perform a complete evaluation of your skin.

The following questions are mostly answered by a yes or no,some are multiple choice.

It is this thorough look at your skin, your habits, and your lifestyle that enable the experts who will be analyzing your results the information needed to return to you.

When purchasing products at a store or even at a spa or salon, you may be asked just a few of the following. How can we possibly choose the right products!

Great Skin Free Personal Skin Care Analysis Questionnaire Sample

Facial Surgery

Have you had laser resurfacing or facial Plastic Surgery in the past 3 months?

Are you planning to have facial resurfacing soon?

Are you planning to have eyelid surgery soon?

Are you planning to have other facial Plastic Surgery soon?

Lifestyle

Do you smoke?

Do you have allergies to any of the following?

• Aspirin
• Talc
• Clindamycin
• Retin-A
• Hydroquinone
• Alpha Hydroxyacids
• Beta Hydroxyacids
• Fragrances
• Hydrogen Peroxide
• No allergies to any of the above

Do you currently take any antioxidant supplements? Do you use Retin-A? If yes: What do you use it for?

• Acne
• Fine Lines

Do you have irritation, sensitivity, flaking from Retin A use?

Are you now using the Acne drug Accutane?

If no , have you used Accutane in the past?

If you used it in the past, how long ago?

Are you currently on a restricted diet?

Do you exercise regularly?

What water temperature do you cleanse with?
Cool, Warm, or Hot

Do you have any special skin problems?

I have adolescent Acne eruptions

I have adult onset Acne

I have deep cystic Acne

I have oily skin, but no eruptions

I have dry skin with Acne outbreaks

I have lines and wrinkles from sun damage (photo aging)

I have combination skin, dry in some places, oily in the T zone

I have hyperpigmentation (brown spots from sun or Acne)

I have Acne scarring

I have smooth, normal skin

I have enlarged pores

I have no special skin problems

Are you susceptible to cold sores?

Your Current Skin Products

What types of cleansers are you now using?
Soap
Cleanser
Lotion
Cream
Are you currently using bar soap to cleanse your face?
Do you use any skin care products which contain mineral oil, lanolin, alcohol, color, fragrance, or formaldehyde?

Questionnaire Sample Continued

What type of skin do you have?

Dry
Normal to Dry
Normal
Normal to Oily
Oily
Problem/Blemished

What product line are you currently using?

Have you used glycolic?
What percentage?
Don't know If you've used glycolic

Women Only
Are you taking oral contraception?
Are you pregnant, trying to become pregnant, or breast feeding?

Men Only
Do you ever experience irritation from shaving?
Do you experience ingrown hairs?

Oil Secretion

What time of day do you first notice oil?
15 to 30 minutes after cleansing
Midmorning 9 to 10 am
Lunch time 12 PM

Late Day 4 to 5 PM
Totally Dry I do not experience breakthrough oily shine during the day
Do you experience skin break-outs?

Moisture And Hydration

How much plain water do you consume daily?
1-2 cups
3-4 cups
5-6 cups
7+ cups

When you are in the sun for extended periods, do you use a sunscreen/sun block?

Capillary Activity
Do you have a tendency to redness in skin tone?

Skin Type

Which of the following most closely describes your skin type?

Very fair skin tone blond or redhead,freckles, burns easily,never tans

Light skin tone, will tan, but usually burns.

Light to olive skin tone, sometimes burns, hazel eyes, auburn to light brown hair.

Medium brown skin tone, rarely burns.

Dark brown skin tone, very rarely burns, dark eyes, dark hair.

Dark skin tone, burn resistant, dark eyes.

Skin Quality

Please tell us about the following qualities of your skin:
Facial Lines
A few or none around the eyes

Around the eyes and on the face

A round the lip area

Do you have eye area puffiness?

Do you have dark under eye shadows?

seldom-occasionally-frequently

Your skin texture is:

bumpy and uneven
smooth and soft
coarse and grainy

Do you have blackheads?
few or none
some, especially in the T-zone problem

Do you have small, red broken capillaries that show through your foundation?

A few
None

Does your skin have dry patches?

never
occasionally
frequently

Is your skin extremely dry?

Your skin pore size:
enlarged all over
some
enlarged in the T-zone
nearly invisible

Your skin thickness: very thick-normal-very thin

Do you wear glasses?

What results are you looking for?

Clear up Acne eruptions
Clear up blackheads
Minimize size of pores
Decrease oilyness of skin
Diminish the appearance of capillaries on the face
Lighten skin complexion or hyperpigmentation areas
Restore skin elasticity
Hydrate the skin
Smooth skin texture
Diminish flakiness of skin
Lighten Acne scarring
Diminish wrinkles and fine lines
Pre-facial surgery skin preparation
Post-facial surgery skin care
No special results, just the best regimen for my skin

What do you like best about your facial skin?
What do you like least about your facial skin?

Please do not be intimidated by the length of the form, it will take no more than ten minutes or so to complete, perhaps less now that you have pre-viewed and had some time to think of your answers.

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Great Skin Free Personal Skin Care Analysis
Site Author: Tanna Mayer
Updated: February 22, 2013

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