ONLINE ANALYSIS QUESTIONNAIRE
         
For Product Recommendation
         
 

Instructions : Answer each question and submit the form. We will send back an analysis and product recommendations chosen for your specific skin care needs.

IMPORTANT: The following profile questionnaire is used to evaluate individual skin care needs for home product use. The information is completely confidential and used only for analysis. By sending this form back to Marco Rizzo, M.D. Plastic Surgery Clinic, the sender confirms that the answers given are correct and that any information relevant to the recommendation of skin care products has not been withheld. You must give us your valid e-mail address to receive a response!

  
         
  Name:    
         
  Address:    
         
  City:    
         
  State:    
         
  Zip:    
         
  E-mail:    
      (You must give us your e-mail address or we will not know where to send your analysis)  
  Phone:    
         
  How did you find our website? Yahoo, Excite, friend, another website, Yellow Pages, etc.:    
         
  THE BASICS  
         
  1. Your Age is:    
         
  Your Sex is:  
Male Female
 
         
  LIFESTYLE  
         
  2. Have you undergone laser resurfacing in the last three months?  
Yes No
 
         
  3. Do you smoke?  
Yes No
 
         
  4. Do you have allergies to any of the following? (Check all that apply.)  
Aspirin Talc Latex
Clindamycin Retin-A Hydroquinone
Alpha/beta-hydroxyacids Fragrances Hydrogen Peroxide
No allergies to any of the above
 
         
  5. Do you currently take any antioxidant supplements?  
Yes No
 
         
  6. Do you use Retin-A?  
Yes No
 
         
  7. Are you now using the acne drug Accutane?  
Yes No
 
         
  If no , have you used Accutane in the past?  
Yes No
 
         
  8. Are you currently on a restricted diet?  
Yes No
 
         
  9. Do you exercise regularly?  
Yes No
 
         
  10. What water temperature do you cleanse with?  
Cool Warm Hot
 
         
  11. Do you have any special skin problems? (Check any 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  
         
  YOUR CURRENT SKIN PRODUCTS:  
  Please answer these questions about your current skin care products:  
         
  12. What types of cleansers are you now using?  
soap cleanser lotion cream
 
         
  13. Do you use any skincare products which contain mineral oil, lanolin, alcohol, color, fragrance, or formaldehyde?  
Yes No
 
         
  14. What type of skin do you have? (Check one.)  
Dry Normal to Dry Normal
Normal to Oily Oily Problem/Blemished
 
         
  WOMEN ONLY :  
         
  15. Are you taking oral contraception?  
Yes No
 
         
  16. Are you pregnant or trying to become pregnant?  
Yes No
 
         
  MEN ONLY :  
         
  17. Do you ever experience irritation from shaving?  
Yes No
 
         
  18. Do you experience ingrown hairs?  
Yes No
 
         
  OIL SECRETION :  
         
  19. Do you experience breakthrough oily shine during the day?  
Yes No
 
         
  MOISTURE HYDRATION :  
         
  20. How much plain water do you consume daily?  
1-2 cups 3-4 cups 5-6 cups 7+ cups
 
         
  21. When you are in the sun for extended periods, do you use a sunscreen/sunblock?  
Yes No
 
         
  CAPILLARY ACTIVITY :  
         
  22. 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.  
      White 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.  
      African-American, very dark skin and eyes, burn resistant.  
         
  SKIN QUALITY:  
  Please tell us about the following qualities of your skin:  
         
  23 . Facial Lines:  
a few or none some around the eyes
around the eyes and on the face around the lip area
 
         
  24 . Do you have eye area puffiness?  
No Occasionally Frequently
 
         
  25. Do you have dark undereye shadows?  
seldom Occasionally Frequently
 
         
  26. Your skin texture is:  
bumpy and uneven smooth and soft coarse and grainy
 
         
  27. Do you have blackheads?  
few or none some, especially in the T-zone problem
 
         
  28 . Do you have small, red broken capillaries that show through your foundation?  
problem (nose/cheeks/chin) a few none
 
         
  29. Does your skin have dry patches?  
never Occasionally Frequently
 
         
  30. Your skin pore size:  
enlarged all over some enlarged in the T-zone nearly invisible
 
         
  31. Your skin thickness:  
very thick normal very thin
 
         
  32. Do you wear glasses?  
Yes No
 
         
  33. What results are you looking for?  

Clear up acne eruptions

 
      Clear up blackheads

  
      Minimize size of pores

  
      Decrease oilyness of skin

  
      Diminish the appearence 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

  
         
  Did you give us your e-mail address? We must have it to send your results back to you! Up to e-mail field  
         
  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. Dr. Marco Rizzo analyzes your skintype and suggests products soley on the completeness and accuracy of the information provided by you. Any products purchased by you, in response to PSRC suggestions based on information you have provided in this form, are your responsiblility and cannot be returned to Dr. Marco Rizzo.		  
       
 
 
 
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