Sage Skin Care Profile

PERSONAL AND CONFIDENTIAL

Now that you have placed an order with Sage Skin Care, please fill out this profile in as much DETAIL as you can provide. Many factors effect your skin your skin and its conditions, therefore the detail allows me to make a more thorough and accurate analysis and blend the products you have ordered to exactly match the conditions and needs of your skin.

Personal Information:
*Required

First Name*		Work Phone
Last Name*		Home Phone
Street Address*		FAX
Address (cont.)		E-mail*
City*		Date of Birth
		Age
		Sex*
State/Province*
Country*
Zip/Postal Code*

How did you hear about Sage?

Acne Forum
Altavista
AOL
Ask Jeeves
AT&T WorldNet
Beauty Buzz
Bizrate
Compuserv
Cosmetic Connection
Dealtime
Earthlink
Emakemeup
Excite
Freeserv
Google
HealthBoards
Hotmail
Icompact
Info Space
Lycos
Make Up Alley
MSN
My Points
Naturallycurly
Netscape
New York Times
On-line Magazine
On-line review
Referral
Sage Forum
The Knot
Overture
Yahoo
Other

If a search engine which one?

If a referral, please give the name, so we can send a Thank You and Gift Certificate

Medications

Your medications and/or vitamins effect your skin, it's condition, and appearance. Please be very specific about what you take and when you started taking it.

Which of the following medications do you take, and when did you start taking them?

	Name	Date Started
Hormones
Birth Control Pills
Antibiotics
Antihistamines
Antidepressants
Homeopathic Medicines
Retina
Micro Retina
Renova
Avita
Benzoyl Peroxide (please state %)
Metragel
Additional medication or vitamins

Sun Damage

Natural Hair Color
Eye Color
Skin Color
Do you smoke?
If you smoke, how many packs per day?
Do you sunbathe/sit in the sun?
Do you wear a hat or visor while in the sun?
How many hours are you "tanning" at a time?
Do you use tanning beds?
If "yes", how many hours per week?
Do you use sun block every day?
What Strength?
Do you use sun block during outdoor activities?
If yes, what strength?
How many hours per day do you spend outside in summer?
How many hours per day do you spend outside in winter?
Do you have any discoloration you are concerned about?
If so where on your face?
What color?
Where on your body?
What color?

Skin Condition
Do you have fine lines on your face?
If so, where?
Do you have wrinkles on your face?
If so, where?
How would you describe the texture of your skin?
How would you describe the color of your skin?
Do you have Rosacea? (red or pink, discolored, uneven skin on your face)
If so, where?
How long have you had this condition?
Does anything cause it to flare up or appear worse to you?

Does your skin flush or blush when exposed to the following:
Heat
Humidity
Cold Weather
Wind
Exercise
Do any of the following foods or drinks irritate your skin in terms of causing flushing/blushing?
Alcohol
Hot Tea/Coffee
Hot/Spicy Foods

Skin Type
Do you feel oily during the day?
If yes:
How soon do you notice an oily feeling after cleansing?
Where do you notice the oiliness after cleansing?
How soon do you notice the oiliness after applying make-up?
Where do you notice the oiliness after you apply makeup?
On the areas of your face where you are oily, do you notice more oiliness in the:
Do any of your oily areas feel dry during winter?
If so, which areas?
Do you feel dry during the day?
If yes, please describe where you feel dry
How soon do you notice the dry feeling after cleansing or applying makeup?
On the areas of your face where you are dry, are you drier in the:
Are there any changes to the dry areas of your face during the summer?
If so, please describe:

Acne
Do you have breakouts that concern you?
If yes:
Please be specific and tell where on your face you have acne
Where are the largest Zits generally located?
Tell us specifically where on you body you have acne
Do any immediate family members have, or have they ever had acne
Father	Mother	Brother(s)	Sisters(s)
At what age did you start breaking out?
If female, do you break out or "flare up" during your menstrual cycle?
Do you breakout of "flare up" during periods of stress?
Choose one or more of the following to describe the type of acne you have:			Blackheads
			Whiteheads
			Small pimples
			Big Mothers (large lesions)
			Closed comedones (small, hard bumps under the skin)
Please list all acne products or ingredients that have not worked for you in the past:
Is there any product or ingredient that has made your acne worse?
What was it?

Sports

Please list any sports you do on a regular basis

Do you workout?

How many days per week do you work out?

For how long a period of time do you work out?

Do you perspire when you work out?

Skin Care and Makeup
Please tell us what skin care products you currently use:
How long have you used this product line?
Is your face better or worse since you have used it?
Please list the brands you currently use for the following products:
Foundation
Powder
Blush
Other
Are you allergic to any product or ingredient that you know of (please specify)?

Is there anything else I need to know about your skin in order to help you achieve your goals?

Please press the submit button only once