Please answer the following questions by circling the number which best describes you. Your clinician will total your score during the consultation.
If your score is:
your skin type is:
0 – 3
4 – 7
8 – 11
12 – 15
16 – 19
20 – 24
Additional skin response questions:
I have answered the questions contained in this questionnaire to the best of my knowledge. I understand that it is my responsibility to inform my practitioner of my current health conditions while seeking treatment as a patient. I will update this information as it occurs.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.
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