Sunshine Botanicals | Questionnaire

Middle Initial:

Customized Skin Evaluation What would you most like to change about your skin? Is your skin the best that it can be? What about your skin texture – are the pores small and clear, or is your skin congested? What about your skin color – is it clear and even, or discolored and blotchy? What products are best suited to your skin type? How can you protect your skin from environmental damage, dryness and premature aging? This personalized analysis is FREE to all visitors. When you submit your information to us, our founder will create a customized daily skin care routine this is perfect for you, and it will deliver real results for healthy, clear skin. To better assess your needs, please complete the following information and upload photos of your facial skin (front and side view if possible). This will help us design the most effective treatment program for optimal results. If photos are not possible, just send the info below. Thank you and we are happy to have you visit Sunshine Botanicals! Items marked with an * are required fields.
*First Name:	*Last Name:	*Email:
*Phone Number:	*Age:	*Gender: Female Male
Personal Information
Please check if presently using any of the following:
Retin A	Accutane	Topical Vitamin C
Hydroquinone	Glycol Acid/Alpha Hydroxy Acid	Any other active or medicated topicals
Ethnic Background:
Caucasian	Hispanic	Asian
African American	Native American	Other
I have had the following procedures:
Cosmetic Surgery	Botox Injections	Fillers
Skin Cancer	Dermatitis	Keloid Scarring
Laser Resurfacing	Chemical Peels	Other (specify)
Do you have any of the following conditions that you would like to address?
Hyperpigmentation (Brown Spots)	Acne	Acne Scarring
Sun Damage	Enlarged Pores	Fine Lines & Wrinkles
Age Spots	Surgical Facial Scars
Do you experience any of the following skin related symptoms:
Redden easily	Reacts quickly to touch/topicals	Weakened/Revealed Capillaries
Blotchy White/Red Patches	Rosacea	Diffused Redness
Weepy raised sores	Itchiness	Discomfort
Skin Texture:
Coarse	Smooth
Thin, Transparent	Thick, Pebbly
Skin Irregularities:
Razor Bumps	Ingrown Hairs	Excessive Dryness
Excema	Psoriasis	Excessive Oiliness
Impurities	Heavily Congested	Enlarged Pores
Blackheads/Whiteheads	Any Other Skin Irregularities
What medications do you take on a regular basis?
Have you ever had Herpes (cold sores)?
Yes	No
Have you ever been treated with Zovirax or any medication for Herpes?
Yes	No
Are you presently under a physician's care for any reason?
Yes	No
Do you use Biore or snore strips?
Yes	No
Do you smoke?
Yes	No
Do you take nutritional supplements?
Yes	No
Are you currently having any facial treatments done?
Yes	No
If so, what treatments and how often?
How is your general health?
Excellent	Good
Fair	Poor
*What skin care products are you currently using?
What would you most like to change about your skin?
Female Clients Only: Are you on hormone replacement therapy?
Yes	No
Are you presently taking birth control pills?
Yes	No

Personal Information