Name:
Email:
1. After cleansing your face, your skin feels:
Refreshed
Tight and stretched
Itchy with slight redness
Same as before cleansing
2. Do your current facial skin care products irritate your skin after use?
Yes, they occasionally irritate my skin
Yes, they often irritate my skin
No, they do not irritate my skin at all
Not applicable. I do not use facial skin care products
3. After cleansing, how long does it take for your skin to turn oily:
30 mins
1 hour
3 hours
Half a day
4. After application of foundation powder, observe your skin's texture in the mirror. What is the most obvious to you?
Smooth but few lines under the eyes
Patchiness and an uneven feel
Both patchiness and lines/ creases
Not applicable. I do not use foundation powder.
5. Before the start of your monthly period, your skin:
Feels normal
Feels very oily
Suffers from break-out
Not applicable
6. When did you realize that you have pigmentation/freckles?
Do not have any
Since at a young age/ teenage years
During or after pregnancy or taking medication
After frequent exposure to sunlight
7. When exposed to the sun, how does your skin react?
Skin Burns
Skin first burns, then tans
Skin tans easily
Skin condition remains the same
8. Look into the mirror and decide what best describes your wrinkle condition
Few fine lines under eyes
Numerous fine lines, with sagging skin, and lines around the
mouth
Some wrinkles with dull looking skin color
Some wrinkles with oily and dull looking skin
9. Do you have dark circles or puffiness around the eyes?
None
Puffiness
Dark circles
Both puffiness and dark circles
10. Your age group is:
Below 18 years old
18 - 25 years old
26 - 35 years old
Above 35 years old
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