skin images

Skin Assessment


Fields marked with * are required.






Male Female

Retin A
Topical Vitamin C
GlycolAcid/Alpha Hydroxy Acid
Accutane
Hydroquinone
Any other active or medicated topicals

Caucasian
Asian
Hispanic
Other (specify)

Cosmetic Surgery
Anti-Wrinkle Injections
Fillers
Skin Cancer
Dermatitis
Keloid Scarring
Laser Resurfacing
Chemical Peels
Other (specify)

Hyperpigmentation (Brown Spots)
Acne
Acne Scarring
Sun Damage
Enlarged Pores
Fine Lines & Wrinkles
Age Spots
Surgical Facial Scars

Yes No

Redden easily
Reacts quickly to touch/topicals
Weakened/Revealed Capillaries
Blotchy White/Red Patches
Rosacea
Diffused Redness
Weepy raised sores
Itchiness
Discomfort

Coarse
Thin Transparent
Smooth
Thick
Pebbly

Razor Bumps
Excessive Dryness
Psoriasis
Impurities
Enlarged Pores
Blackheads/Whiteheads
Ingrown Hairs
Excema
Excessive Oiliness
Heavily Congested
Tight Filled Pores
Any Other Skin Irregularities


Yes No

Yes No
Yes No

Yes No

Yes No

Yes No
Yes No

Yes No
Yes No

Yes No
Yes No

Yes No

Yes No

Yes No

Yes No

Yes No


Excellent Good
Fair Poor


Female Clients Only

Yes No
Yes No
Yes No