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Questionnaire
Beauty Boutique Questionnaire
Please enable JavaScript in your browser to complete this form.
Name
*
Age
*
Sex
*
Email
*
Phone Number
*
City
*
Are You Pregnent Or Breast Feeding
*
Yes
No
Not Applicable
1. How does your skin feel 15 minutes after washing your face?
Dry
Dry and hot/sensitive
Dry and stretched
Very dry, rough and flaky
Normal
Oily
Oily and with open pores
Normal but with oily areas on nose, forehead and/or chin
It changes, based on the weather and season
2. How much sun are you exposed to on a daily basis (even if you are travelling by car or bus)?
Less than 15 minutes a day
15-60 minutes a day
60-120 minutes a day
More than 2 hours in a day
I am an athlete / swimmer / architect / salesman / contractor / real estate agent
3. What kind of facial pigmentation do you suffer from?
None
Freckles
Uneven skin tone
Pigmentation around sensitive areas (around the eyes and the lips)
Dark and thick skin on forehead, cheek bones and/or neck folds
Birthmark
Mark left by a burn
4. Do you suffer from pimples? Tell us more...
None
I have pimples and very oily skin
I have pimples and very dry skin. I don't use any creams as they make my pimples worse
I only have a few pimples but they leave dark marks
I have pimples with facial redness
I have pimples with freckles and/or melasma
I am over 35 years old and I suffer from pimples
I am under 18 years of age and I suffer from pimples
I have pimples on my chest, back and/or shoulders as well
I have pimples on my scalp as well
I have only (or mostly) blackheads and whiteheads
5. Do you suffer from dandruff?
No
I have dandruff and oily scalp
I have dandruff and oily/smelly scalp
I have dandruff and small painful boils on my scalp
I have dandruff and dry/pink scalp
6. Do you have dry hands?
Yes
No
7. Do you have cracked feet?
Yes
No
8. Do you have wrinkles on your face?
No. I am in my 20's
No. I am in my 30's and keen on starting anti-ageing creams to delay wrinkles
Yes. I have normal skin with fine lines
Yes. I have dry skin with fine lines
Yes. I have oily, pimple-prone skin with fine lines
Yes. I have pigmented skin with fine lines
I have deep lines and wrinkles
I have lines, wrinkles and skin sagging
9. What kind of hair do you have?
Normal
Dry and damaged (split ends)
Dry and unmanageable but not damaged (no split ends)
Chemically treated
Oily
Thin
Falling
Frequent use of flat irons/curling device
10. I want advice on what kind of moisturizer do I need to use for my body? I have...
Dry skin
Dry and bumpy skin (with pimples or keratosis pilaris)
Normal
Body Odour
Itch-prone or Eczema-prone skin
11. What kind of lips do you have?
Normal
Dry
Dry and Dark
Dry, itchy, chapped and suffering from allergies
12. Tell us about the skin around your eyes..
Normal
Dark circles
Puffiness and bags
Normal but with scanty eyelashes
I have eye allergies, eye itching/watering, eczema and/or sensitive skins
I have allergic sinus problems
13. Have you ever had an allergic reaction to any cosmetic, medicated cream or facial? If so, please name the cream/facial
14. Tell us about your present skin and hair care regime? (This may include face wash, toner, scrub, serum, sunscreen, under eye cream, moisturizer, home remedies, face packs, parlour treatments/packs/creams, hair oil, shampoo, conditioner, hair serum, hair gels, hair color, henna etc.)
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About Dr Sunaina
Patient Information Leaflets
Medical
Cosmetic
Allergology
Treatments & Services
Aesthetic
Medical
Plastic Surgery
FAQS
Blog
The Beauty Boutique
About Beauty Boutique
Questionnaire
Brands
Conditions
Patient Instructions
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