Skin Assessment - Cosmoderm

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Complete our free online skin assessment and find out which products or treatments are best suited for your individual skin or body concern.

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Name and Surname

Email

Contact Number

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Gender

Male

Female

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Area to be assessed

Face

Body

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How long have you had this concern or condition

0-3 months

6-12 months

1-2 years

More than 2 years

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Lifestyle Questions

	Yes	No
Do you smoke?
Do you exercise?
Do you follow a restricted diet?
Do you have more than 4 caffeinated beverages daily?
Do you experience high stress levels?
Do you experience high levels of fatigue?
Are you expose to high levels of daily sun?
Do you wear SPF Daily?

Do any of the following apply to you

Pregnant or trying to become pregnant (female clients only)

Hormone treatment (female clients only)

Lactating (female clients only)

Severe Eczema

Lupus Erythematosus or any other auto immune disease

Do you have a thyroid condition

Do you have a hormone imbalance

Are you taking or have you taken Isotretinoin (Roacctune, Oratane, Accetane)

Do you have any allergies (please specify below)

Please specify any allergies

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