First Name		Work Phone
Last Name		Home Phone
Street Address		FAX
Address (cont.)		E-mail
City		Date of Birth
		Age
		Sex	Female Male
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?

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Sun Damage

Natural Hair Color	Blonde Brown Black Red Gray White -------------
Eye Color	Blue Brown Black Green Gray Violet ------------------
Skin Color	Fair Medium Olive Asian Brown Dark Brown/Black ---------------
Do you smoke?	Yes No -----------------
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?	Yes No ---------------
How many hours are you "tanning" at a time?
Do you use tanning beds?	Yes No ---------------
If "yes", how many hours per week?
Do you use sun block every day?	Yes No -------------------
What Strength?
Do you use sun block during outdoor activities?	Yes No -----------------
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?	Yes No ---------------
If so where on your face?
What color?
Where on your body?
What color?

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Skin Condition
Do you have fine lines on your face?	Yes No ----------------
If so, where?
Do you have wrinkles on your face?	Yes No --------------
If so, where?
How would you describe the texture of your skin?	Smooth Rough uneven dry flaky irritated -----------------
How would you describe the color of your skin?	Healthy Unhealthy Rosy Dull Flat -------------
Do you have Rosacea? (red or pink, discolored, uneven skin on your face)	Yes No Don't know ---------------
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	Yes No --------------
Humidity	Yes No --------------
Cold Weather	Yes No ------------
Wind	Yes No --------------
Exercise	Yes No ------------
Do any of the following foods or drinks irritate your skin in terms of causing flushing/blushing?
Alcohol	Yes No ---------------
Hot Tea/Coffee	Yes No -------------
Hot/Spicy Foods	Yes No ---------------

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Skin Type
Do you feel oily during the day?	Yes No -------------
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:	Winter Summer No Change --------------
Do any of your oily areas feel dry during winter?	Yes No --------------
If so, which areas?
Do you feel dry during the day?	Yes No ----------------
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:	Winter Summer No Change --------------
Are there any changes to the dry areas of your face during the summer?	Yes No -------------
If so, please describe:

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