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Appearance
Cosmetics
Medical History
Environment
How does your forehead and cheeks appear 2 hours after washing your face and not applying any skin care products ?
Very rough, flaky or ashy
Tight
Well hydrated with no reflection of light
Partly shiny (usually T-Zone), cheeks slightly tight or restore moisture
Shiny with reflection of bright light
Does your skin feel tight if not moisturized ?
Always
Yes when air is dry
Sometimes
Rarely
Never
In photos, does your face appear shiny/oily ?
Never
Previously was, faded progressly during aging
Sometimes
Frequently
Always
Is your face oily in the T-Zone ?
Not oily but dry
Never
Sometimes
Frequently
Always
Do you have any dark spots or patches on your upper lip or cheeks ?
No
Not sure
Yes, slightly noticeable
Yes, very noticeable
Yes, a lot
Do you have or ever had small brown spots (freckles or sun spots) on your face, chest, back or arms ?
No
Yes, a few (1 to 5)
Yes, many (6 to 15)
Yes, tons (16 or more) all over the body
Yes, tons (16 or more) and they are mainly in face area
Do you have facial wrinkles ?
No
Yes but only when I am smiling, frowning or lifting my eyebrows
Yes, a few when I am not smiling, frowning or lifting my eyebrows
Yes, a lot even when I'm not smiling, frowning, or lifting my eyebrows
Does your face get red after moderate exercise or exhibiting strong emotion ?
Never
Occasionally (Because of rare excercise)
Sometimes
Frequently
Always
Does any skin care or cosmetic products cause your face to breakout, get a rash, itch or sting ?
Never
Rarely
Often
Always
I don't apply any product
Does any sunscreen product make your skin to break out, itch, or turn red ?
I never used any sunscreen product
Never
Rarely
Often
Always
Does any fragranced product make your skin to break out, itch or feel dry ?
Never
Rarely
Often
Always
I never use these types of products
Did you get dark spots on your face when you were pregnant, on birth control pills or taking Hormone Replacement Therapy (HRT) ?
Not applicable
None
One
A few
A lot
Has anybody in your family been diagnosed with any skin disease ?
Not sure
No
One family member
Several family members
Many of my family members have skin disease
How old does/did your mother's facial skin look ?
Younger than her age
Her age
Older than her age
Much older than her age
Not applicable
How old does/did your father's facial skin look ?
Younger than his age
His age
Older than his age
Much older than his age
Not applicable
In cold/dry environment, without applying any moisturizer, how does your skin appears ?
Don't know
Very dry or cracks
Tight
Normal
Shiny or I never felt that I need moisturizer
When exposed to sunlight for the first time you remember, what happened to your skin after several months ?
No any feeling
Burns only
Burns then gets darker
Gets darker
Not sure
Do the dark spots on your face get worse when you go out in the sun ?
I wear sunscreen on my face every day and never get sun.
No
Not sure
Slightly worse
Much worse
In the last 5 years, how often have you tanned your skin intentionally or unintentinally through the outdoor activities ?
Never
Once in a quarter
Once a month
Once a week
Daily
Please describe the air pollution condition where you live
The air is fresh and clean
I live in a place with clean air most of the time
The air is slightly polluted
The air is polluted seriously
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