Personalized Skin Care Analysis

Illustre Essenza Skin Care Analysis for Product Recommendation

Please complete the form below for a complimentary skin care analysis done by our expert consultants thru Avanti Skin Centers or through our other Licensed Professionals. Please make sure that you give an answer to every question on the form below; all answers are required so that we can perform a complete evaluation of your skin.

If you would like to be contacted for a “live” consultation, please check here

You will receive a customized evaluation and product recommendations personalized for your specific skin type and skin care goals.

Privacy Statement: The information you provide is completely confidential and used only for analysis. Please remember to complete each question in order for your information to be analyzed. Incomplete forms will not be processed.

Contact Information:	(all * required field)
Name*
Address*
City*
State*
Zip*
Email*
Phone*
How did you find out website*
Age*
Sex*

Do you smoke*	Yes No
Sun exposure*	Never Sometimes Always
Are you currently using any topical medications on your face*	Yes No
Do you use RetinA*	Yes No
Are you currently taking Acutane or have you taken within the past 6 months*	Yes No
Have you ever used Acutane*	Yes No
Have allergies to the following:	Aspirin* Parabens* Hydroquinone* Alpha Hydroxy Acids* Beta Hydroxy Acids* Hydrogen Peroxide* Fragrance*
Any other allergies not listed above*
Are you on any other medications that cause photo-sensitivity*	Yes No
Are you considering any facial plastic surgery, facial resurfacing or other medical procedures in the next 3 months *	Yes No
Have you had any medically supervised treatments in the last 3 months*	Yes No
How much water to you consume on a daily basis*	8-16- oz 16-32 oz 32+
Have you been diagnosed with any skin conditions*
Have you had any surgery on your face	In office Out-patient Hospital None
Do you have any special skin problems*	Acne (adult)* Cystic Acne whether current breakouts or in the past* Oily skin but no breakouts* Dry skin with breakouts* Discoloration from previous breakouts* Discoloration from sun damage* Scarring from previous breakouts* I have fine lines and wrinkles* I have normal pore size* I have enlarged pores* I have combination skin, oily in T zone (forehead, nose, chin)* I have dry skin* I have normal skin* I have sensitive skin* I am susceptible to cold sores* I have a history of keloid scarring*
What skincare line are you currently using to cleanse you face*
What type of cleansing products do you typically like*	Soap* Cleanser –gel* Cleanser – foamy* Lotion* Cream*
Do any of your current skincare products contain Parabens, mineral or petrolatum oils, glycolic acids, alcohol, fragrance or hydroquinone*	Yes No
Are you allergic to certain ingredients in skin care products*	Yes No If so What?
I use products now that contain Glycolic or Beta Hydroxy Acids*	Yes No
I have used products in the past that contain Glycolic or Beta Hydroxy Acids	Yes No
Skin Types
What statement best describes your skin*	Normal* Normal to Dry* Sensitive* Sensitive to Dry* Sensitive with breakouts or blackheads Combination with no breakouts* Combination with breakouts* Oily with breakouts* Oily with no breakouts*
How does your skin react when exposed to sun*	I have very fair skin, light colored hair, freckles, burn easy, never tans* I have a light skin tone, can eventually tan, but usually burn* I am light to medium or olive skin tone, I can sometimes burn, my eyes are hazel and my hair color is naturally auburn or light brown* I have more medium toned skin, tan fairly easily and never burn* I have darker skin tone, dark eyes and hair and rarely burn* I have dark skin, dark eyes and hair and never burn*
Women
Woman*	I am taking oral contraceptives* I am taking bio-identical or other HRT* I am pregnant* I am breast feeding* Think I might be pregnant* Trying to become pregnant*
Have you had any laser hair removal services on your face or neck*	Yes No
When was the last time you had waxing services on your face to remove unwanted hair*	Yes No
How often do you wax, use cream depilatories or bleaching agents on your face	Never* Sometimes* Always*
Man
Do you shave daily*	Yes No
Do you experience razor burn*	Yes No
Do you currently have ingrown hairs or previously had ingrown hairs that bothered you*	Yes No
Have you had laser hair removal services on your face, neck or beard areas*	Yes No
Do you currently have waxing services on your face, neck or back of neck to remove unwanted hair*	Yes No
Oil Secretion
What statement best describe when you first notice any oil on your skin When I first wake up*	Within 15-30 minutes after I cleanse my skin* Within 3 hours of cleansing my skin* By early afternoon* By late afternoon* I am somewhat dry later in the day* I am always dry* I do not have any problems with oil on my face during the day*
Tell us about how you skin looks
Facial lines	Few* Around eyes* Around the lip* Between eyebrows* Forehead* Deep lines and creases*
Do you have an overall ruddiness to your skin*	Yes No
Do you flush easily	Face* Neck* Chest
Do you have a lot of broken capillaries or blood vessels around your nose or on your face*	Yes No
Do they show thru makeup*	Yes No
Do you have dark undereye shadows*	Never* Sometimes* Always*
Do you have puffiness under your eyes*	Never* Sometimes* Always*
Describe your skin texture	Even* Bumpy* Coarse*
Do you have any blackheads or whiteheads*	Around nose* Forehead* Chin*
Does your skin have any dry patches*	Never* Sometimes* Always*
Your overall pore size	Small* Medium* Large* Large in T-zone*
Thickness of skin	Normal* Thick* Very thick* Thin* Translucent*
Do you use SPF on your face*	Every day Sometimes when I am going to be outside Never
What SPF # and brand
What is your primary goal for your skin	Decrease the appearance of fine lines and wrinkles* Even overall skin tone* Reduce pigmentation from sun exposure* Reduce breakouts Hydrate the skin Reduce flakiness on skin Minimize the appearance of pores Reduce broken capillaries and overall ruddiness Improve skin elasticity Smooth skin texture Clear up breakouts including blackheads Pre-surgery Post surgery I am just looking to maintain the health of my skin Preventative maintenance
Is there anything else you would like to tell us about the condition of your skin that was not covered by previous questions?
Briefly tell us:
What do you like best about your skin*
What do you like least about your skin*
How much time are you willing to devote to the care and maintenance of your skin on a daily basis*
Would you like to sign up for our monthly newsletter*	Yes No
Would you like to be alerted of any monthly specials*	Yes No

We do not address any medical problems nor can we make any specific medical diagnosis about any disease or disorder of the skin. Please contact your medical provider for an analysis of your skin.

Disclosure:

This questionnaire is submitted on line and is not meant to replace a face-to-face evaluation by a licensed professional medical professional like physicians or estheticians.

Products recommended are based on your completeness and accuracy of all answers asked in our questionnaire. If you would like to be referred to one of our partners, please click here*

Any products purchased by you in response to LuminosoStudios.com for Illustre Essenza suggestions based on information you have completed in this form are your sole responsibility and cannot be returned to LumnosoStudios.com for any reason other than obvious manufacturers defect or damage during shipping.

Used as directed, our products are safe and effective. However, because everyone's skin differs, no guarantee is made or implied as to precise results for any of our products. We cannot be responsible, and are not liable for any outcome or damages resulting from information obtained from us in either direct or indirect form based on your responses to this questionnaire. We assume no responsibility or liability for misuse of a product or for any consequences or injuries as a result of using a product.
By checking this box I agree to the above terms.

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