Interactive Skin Care Analysis



Welcome to the TotalSkinCare.com interactive skin care analysis.

The purpose of this exercise is to ask you to think about the type of skin you have and how you are currently caring for it, and second, to give us an opportunity to offer you some feedback!

Whether you are just looking for guidance on general skin care or have some specific concerns about your skin, we would be pleased to share our thoughts and suggestions with you.

In the future, TotalSkinCare.com will provide in-depth discussions about general skin care, as well as specific skin ailments and suggested treatment. As always, you are welcome to contact us by email to discuss your personal skin care in greater detail.

* Denotes required field

Personal Information
 
Name:
Address:
City:
State:    *Zip:
Country:
*Email:
May we add you to our MailList? Yes     No
Daytime Phone:
Evening Phone:
 
Where did you find out about the TotalSkinCare?
Yahoo Radio Advertisement
Infoseek A TotalSkinCare Customer
Excite/Webcrawler Yellow Pages
HotBot Washington Post
GoTo Magazine
SearchHound Direct Postal Mail
iVillage Direct E-Mail
USA Today Wall Street Journal
Other Search Engine
     (please specify below)
     		Dr. Cohen's website
    (www.bjcohen.com)
 
Skin Assessment Questionnaire
 
*I am: Female      Male
 
My age is: or my age range is 18-30 31-49 50+
 
*I smoke or have smoked within the last 5 years: Yes No
 
*My "Fitzpatrick" skin type is:
 

Very fair skin, I never tan, I burn

Light skin, I may tan, but I usually burn

Light/medium complexion sometimes I tan, sometimes I burn

Medium complexion I usually tan, rarely burn

Dark complexion - I never burn (Hispanic, Asian, Southern European)

African American, I never burn

 
*I would describe my skin type as:
 
 

Dry/sensitive

oily

combination (T-zone)

 
I am allergic or sensitive to:
 
*Alpha or Beta Hydroxy Acids: Yes No
Hydroquinones: Yes No
Retin A: Yes No
 
I currently take oral vitamin supplements:

Yes  No
 
I am using the following products as part of my skin care routine:
 
Soap
Moisturizer creme lotion
Cleanser
Toner
Lightening/bleaching agent
Sun block
Tanning agent
Hypoallergenic make-up
Retin-A or Renova I experience side effects:
yes no
Antiwrinkle creme lotion patch
Facial masque
 
*I would like some ideas on how to manage the following skin related concerns:
 
Preventive maintenance how to avoid premature aging of healthy skin
Scalp treatment, i.e. thinning hair
Persistent acne, such as:
    "teenage" (oily skin) adult deep cystic acne
Acne scarring
Large pores
Facial wrinkles and fine lines
Sun damage such as skin roughness spotting
Dark pigmentation spots
Eyes: fine lines & wrinkles puffiness under eye bags
 
I am using skin care products from the following brands:
 
Cellex-C
Cellex-C Advanced C
Exuviance (by NeoStrata)
Gly Derm
Gly-Med Plus (by Advanced Aesthetics)
Glytone (by Genesis Pharmaceuticals)
Glytone Clarifying System
Jan Marini
M.D.Forte (by Allergan)
NeoStrata
Neova (by ProCyte)
Obagi
PCA
Physician Elite Rx (by Glymed)
Physicians Complex
Procyte
SkinCeuticals, Inc
Total Skin Care
Other
 
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