REVITALIFE

Personally Customized Skin Care Regimen

Please answer the questions in the form and send it for me to be able to customize a skin care regimen exclusively for your skin type. Thank you!

Name:
Email Address:
AGE
Sex
Address
Contact no.
Mobile No.
Type of skin: Oily, dry or combination?
Why do you say so?
Sensitive or resistant skin? Degree of sensitivity or resistance?
Your basis of saying so...
Pimple or Acne prone?
If so, cystic or not?
What triggers your breakout?
Do you get hyperpigmentation after acne or any skin trauma?
Have hyperpigmentation? What type? Since when? What do you use to lighten it?
Have you used over the counter whitening products of different language characters? What kind/ brand?
Have you used over the counter peeling products? What kind/ brand?
Do you use sunscreen/ sunblock? How often do you use it especially during prolonged exposure to sun?
What brand?
Were you expose to direct sunlight or heat for prolonged hours? If so, how long? Do you apply sunscreen in those occasions every hour?
. Do you have fine lines or wrinkles? crows feet?
What do you use to prevent wrinkles?
Do you get puffy eyelids or dark circles undereye? What do you use to prevent treat them?
Do you have enlarged pores? Any family member who also have enlarged pores?
Your daily regimen...
Any allergies to oral or topical medicines?
Any family member with allergies?
Were you or any member of your family have been diagnosed to have heart disease, kidney disease, cancer, liver disease, Diabetes, Asthma, Allergies? If so, please indicate type of disease and relation to any family member...
Any other skin concern...

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