Cincinnati Plastic and Cosmetic Surgery - face lift, eyelids, nose surgery, lips, botox, laser hair removal, skin peel, etc. in the Cincinnati Area

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Free Customized Skin Care Report

Please fill the questionnaire below and we will send back to you and in-depth analysis of your skin condition and our recommendations.
* Denotes required field

Personal Information

Name:

Address:

City:

State:

*ZIP:

Country:

*Email:

1. May we add you to our MailList?

Yes No

Daytime Phone:

Evening Phone:

2. Where did you find out about the TotalSkinCare?

Skin Assessment Questionnaire

*I am:

Female Male

My age is:

or my age range is 18-30 31-49 50+

*3. I smoke or have smoked within the last 5 years:

Yes No

*4. My "Fitzpatrick" skin type is:

Very fair skin, I never tan, I burn

Light skin, I may tan, but I usually burn

Light/medium complexion sometimes I tan, sometimes I burn

Medium complexion I usually tan, rarely burn

Dark complexion - I never burn (Hispanic, Asian, Southern European)

African American, I never burn

*5. I would describe my skin type as:

Dry/sensitive

oily

combination (T-zone)

6. I am allergic or sensitive to:

*Alpha or Beta Hydroxy Acids:	Yes No
Hydroquinones:	Yes No
Retin A:	Yes No

7. I currently take oral vitamin supplements:

Yes No

8. I am using the following products as part of my skin care routine:

*9. I would like some ideas on how to manage the following skin related concerns:

10. I am using skin care products from the following brands:

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