Save Our Skin :: Godiva, Inc.

* Name

* Age

* Sex

Male

Female

* Address

* City

State

* Country

Telephone No.

* E-mail Address

* Do you take birth control pills?

Yes

* Are you pregnant or breast feeding?

Yes

Have you used any of the following skin medication during the past 3 months?

* Skin Whitener

Presently Using

Tried but Stopped

Brands Used

* Acne Medication

Presently Using

Tried but Stopped

Brands Used

* Tretinoin

Presently Using

Tried but Stopped

Brands Used

* AHA

Presently Using

Tried but Stopped

Brands Used

* Others

Presently Using

Tried but Stopped

Brands Used

Skin Type

* Your Skin is

Somewhat oily in the T-zone (forehead and nose area) but not all over

Undeniably oily all over

even the cheek area

Noticeably dry

Oily or normal with patches of dryness

Not too oily and not too dry anywhere

* Acne Breakouts

You have breakouts once in a while

You are prone to breakouts at least once a month

You have persistent acne

* Sensitivity

Your skin never breaks out in a rash when using new soaps or perfumes

Your skin rarely breaks out in a rash when using new soaps or perfumes

Your skin always breaks out in a rash when using new soaps or perfumes

* Your pores are

Barely noticeable

Larger around the nose and chin area

Large and visible all over

* After washing, your skin is

Oily in the T-zone a few hours later

Oily all over in about 10 minutes

Very irritated and red

* Do hormonal changes affect your skin?

Yes I have breakouts/drier skin about a week before my period

No I do not notice a difference

Special Concerns

* Do you have areas of darker brown (not red) discolorations?

Yes

* If you hold the underside of your right forearm against the top of your left forearm, the top seems darker.

Yes

* Pinch the skin on the side of your hand. Does it take longer than 1 second to bounce back?

Yes

* Look in the mirror. Smile and squint, then release. Do you notice any signs of aging around the eye area?

Yes

* None of these concerns apply to you but you are still interested in general preventive maintenance.

Yes

Do you have other special concerns? Please specify.

Evaluating Your Overall Health

* How often do you exercise?

Frequently

Occasionally

Rarely to never

* How much water do you drink?

8 glasses a day

4 glasses a day

1 glass a day

* Do you currently take vitamins?

Yes

* How would you describe your overall level of stress?

Low

Medium

High

* Verify Verify

Script by Dagon Design

Godiva, Inc.

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