http://www.katyjohnsoninc.com/survey/public/survey.php?

name=skincare
Skin Care Questionnaire
Please take a few minutes to take our skin care questionnaire. Your answers will
help us select the most appropriate skin care products so you will get the maximum
benefits from our program.
Questions marked with a * are required.

*1.

Name

*2.

Age

*3.

Email Address

*4.

Do you have acne?

Yes

No

5.

Where do you breakout?

Forehead
Cheeks
Chin
Nose
T-zone
Jawline
Neck
Other:

6.

Do you have blackheads?

Yes
No

7.

What is your pore size?

large
medium
small
invisible

*8.

Do you wear moisturizer?

Yes
No

9.

10.

How often do you cleanse your face each day?

What facial cleansing products do you currently use?

11.

Are you currently using glycolic acid products?

Yes
No

12.

Do you use bar soap to wash your face?

Yes
No

*13.

What is your skin type?

Sensitive
Dry
Normal

Combination
Oily
Acne Prone

14.

Do you have sensitive skin?

Yes
No

15.

Do you have any special skin issues?

Acne
Oily Skin but no Acne
Dry Skin with Acne
Wrinkes & Lines
Sun Damage

*16.

What type of complexion do you have?

Fair

Medium
Olive
Dark

*17.

What is your skin texture like?

Smooth
Slightly bumpy
Bumpy
Rough

18.

Do you have facial lines?

Yes
No

19.

Do you have puffiness around your eyes?

Yes

No

20.

Do you have dark circles under your eyes?

Yes
No

21.

Do you have dry patches on your face?

Yes
No

22.

Do you have dry skin?

Yes
No

23.

What is your skin thickness?

thick

medium
thin

24.

How many hours do you sleep each night?

25.

Do you wear sunscreen?

Yes
No

26.

Do you exercise?

Yes
No

27.

Do you smoke?

Yes

No

Submit Survey