Welcome to SkinBorn - Medical Skin Enhancement System

The SkinBorn® Analysis Questionnaire

SkinBorn® successfully treats adult acne, eczema, whiteheads, blackheads, and pimples with our medical skin enhancement system.

Use the following form for a FREE personal skin care analysis done by one of our professional estheticians. The results will give you understanding to exactly what you need to solve your skin-related problems. SkinBorn® will send you an evaluation and product recommendations specifically designed for your skin.

The following analysis will help you make informed decisions about how to customize your skin care regime. To ensure a complete evalution of your skin please make sure that you answer every question on the form below.

Privacy Statement: The information you provide in this analysis is completely confidential and used only for analysis.

Contact Information
Name:	Address:
City:	State/Province:
Zip/Postal Code:	Country:
Email:	Phone:
How did you find our website?	Direct Mail	Newspaper Ad
TV Commercial	If other please specify:
The Basics
Your Age:	Your Sex:	Female Male
Facial Surgery
1. Have you had microdermabrasion or facial plastic surgery in the past 3 months?		Yes No
2. Are you planning to have microdermabrasion soon?		Yes No
Lifestyle
3. Do you smoke?		Yes No
4. Do you have allergies to any of the following? (Check all that apply.)
Aspirin Talc Clindamycin Retin-A Hydroquinone Alpha Hydroxyacids Beta Hydroxyacids Fragrances Hydrogen Peroxide No allergies to the above
5. Do you currently take any antioxidant supplements?		Yes No
6. Do you use Retin-A?		Yes No
If Yes:	What do you use it for?	Acne Fine Lines
7. Do you have irritation, sensitivity, flaking from Rentin-A use?		Yes No
8. Are you currently using the Acne drug Accutane?		Yes No
9. If no, have you used Accutane in the past?		Yes No
10. If you have used it in the past, how long ago?
11. Are you currently on a restricted diet?		Yes No
12. Do you excercise regularly?		Yes No
13. What water temperature do you normally cleanse with?		Cool Warm Hot
14. Do you have any special skin problems? (Check all that apply.) 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 (photoaging) 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
15. Are you susceptible to cold sores?		Yes No
Your Current Skin Products
16. What types of cleansers are you currently using?
Soap Cleanser Lotion Cream
17. Are you currently using bar soap to cleanse your face?		Yes No
18. Do you use any skin care products which contain mineral oil, lanolin, alcohol, color, fragrance, or formaldehyde?		Yes No
19. What type of skin do you have? (Check one.)
Dry Normal to Oily	Normal to Dry Oily	Normal Problem/Blemished
Women Only
20. Are you taking an oral contraception? Yes No
21. Are you pregnant, trying to become pregnant, or breast feeding? Yes No
Men Only
22. Do you ever experience irritation from shaving? Yes No
23. Do you experience ingrown hairs? Yes No
Oil Secretion
24. What time of day do you first notice oil? 15 to 30 minutes after cleansing Midmorning 9 to 10 am Lunch time 12 pm Midafternoon 2 to 3 pm Late Day 4 to 5 pm Totally Dry I do not experience breakthrough oily shine during the day
25. Do you experience skin break-outs?		Yes No
Moisture Hydration
26. How much water do you drink daily?
1-2 cups 3-4 cups 5-6 cups 7+ cups
Capillary Activity
27. Do you have a tendency to show redness in skintone?		Yes No
Skin Type
28. 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:
29. Facial Lines:	Few or none Some around the eyes Around the eyes and on the face Around the lip area
30. Do you have eye area puffiness?	No Occasionally Frequently
31. Do you have dark undereye shadows?	Seldom Occasionally Frequently
32. Your skin texture is:	Bumpy and uneven Smooth and soft Coarse and grainy
33. Do you have blackheads?	Few or none Some, especially in the T-zone Problem
34. Do you have small, red broken capillaries that show through your foundation?
Problem (nose / cheeks / chin)	A few	None
35. Does your skin have dry patches?	Never Occasionally Frequently
36. Is your skin extremely dry?	Yes No
37. Your skin pore size:	Enlarged all over Some enlarged in the T-zone Nearly invisible
38. Your skin thickness:	Very thick Normal Very thin
39. Do you wear glasses?	Yes No
Almost Done!
40. What results are you looking for? Clear up Acne eruptions Clear up blackheads Minimize size of pores Decrease oilyness of skin Restore skin elasticity Hydrate the skin Smooth skin texture Diminish flakiness of skin	Lighten Acne scarring Diminish the appearence of facial capillaries Lighten complexion / hyperpigmentation areas Diminish wrinkles and fine lines Pre-facial surgery skin preparation Post-facial surgery skin care No special results, the best regimen for my skin
Briefly, is there anything else about your FACIAL skin that was not addressed by the questions above:

What do you like best about your facial skin?
What do you like least about your facial skin?
BY SUBMITTING THIS FORM I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE FOLLOWING: This questionnaire submitted online cannot substitute for the completeness of an in-person consultation with licensed professional skin care estheticians or doctors. The estheticians of SkinBorn® Clinics analyze your skintype and suggest products soley on the completeness and accuracy of the information provided by you. Any products purchased by you, in response to SkinBorn.com suggestions based on information you have provided in this form, are your responsiblility and cannot be returned to SkinBorn.com.