Cat Murphy Skin Care
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> Skin Analysis Questionnaire

By completing this client profile, you will assist us in evaluating your skin type. This information you provide will be used to determine which factors may be affecting your skin so that we may recommend the proper treatments and products.

Please fill in your information below and click on the Send request button when complete. Required fields are marked with an red asterisk. We will follow-up with a phone call (or email if you requested this) with recommendations.

For security reasons, some special characters may be removed from your input.
Date:
Your Name (first & last):
 
 
 
 
Address:
City:
State:   Zip Code:
Day Phone:
Evening Phone:
Email:
Best way to contact:
How did you hear about us:
Would you like to be sent a brochure?    yes no
 
Age group?    Under 30 30 to 40 40 to 50 50 to 60 60+
 
Gender?    Female Male
 
What would you consider your skin type?
    Normal Normal to Dry Dry
Normal to Oily Oily Sensitive Combo
 
Ethnic Background?
    Caucasian Asian African American
Hispanic Native American Other   
 
Do you have any medical conditions?
 
Please list all medications that you take regularly, including hormones, vitamins, etc.:
 
Do you use suncreen?
    Yes No
    UVA:      UVB:      SPF: 
 
Tell us which skin tone describes you best:
    Very fair skin tone, blond or red hair, and may burn easily and quickly
Light skin tone, you will tan but usually burn first
Olive skin tone, light brown hair
Medium skin tone, rarely burns
Dark skin tone, dark hair and eyes, rarely burns
 
Do you wear Mineral Makeup?    Yes No
 
Do you smoke?    Yes No
 
Indicate the quantities (number of glasses) of any of the types of fluids that you consume daily:
 
    Water:      Juices:      Tea: 

Coffee:      Alcohol:      Sodas: 
 
Please list any allergies:
Have you had any reactions to any particular product?    yes no
If Yes, Please describe:
 
Are you presently using any of the following?
    Retin-A Accutane Antibiotics
Alpha Hydroxy Acids Glycolic Acid - If so, what percentage?   
List any other Topicals:   
 
Have you had any of the following procedures?
    Cosmetic Surgery: Face Eyes
Botox Fillers Injectibles
Laser Resurfacing Chemical Peels
 
Have you received a salon/clinic skin care treatment?    yes no
If Yes, what kind of treatment:
 
Please describe in detail (using product brand names) how you are presently caring for your skin:
 
What are your specific concerns about your skin?
    Distended Capillaries Facial Scars Redden Easily
Rosacea Eczema Sun Damage
Please describe any other concerns:   
 
Which conditions would you like to improve?
    Acne Acne Scarring Enlarged Pores
Hyper-pigmentation Fine Lines/Wrinkles
Age Spots Sun Damage Aging
 
What kind of results would you like to achieve from your skin care program?
 
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©Copyright 2011 Cat Murphy Skin Care Salon 		Cat Murphy's Skin Care Salon - 561 Bridgeway, Suites 1 & 2 - Sausalito, CA 94965
Toll Free - 1-800-869-8705   E-mail - info@catmurphy.com
Phone - 415-332-4296