Skin Analysis Form: Personalised Skin Assessment and Care Planning

Name *

Email address *

Message *

Client Details (Comment field) *

How would you describe your skin type most days? *

Normal / Balanced
Dry
Dehydrated (tight but can look oily)
Oily
Combination
Sensitive / Reactive

Age *

Under 20
20–29
30–39
40–49
50–59
60+

Preferred Contact Method *

Email
Text
Phone

Skin Profile (Comment field) *

Primary Skin Concerns (tick all that apply) *

Fine lines / wrinkles
Loss of firmness / sagging
Uneven skin tone / pigmentation
Dullness / lack of glow
Acne / breakouts
Congestion / blackheads
Redness / irritation
Enlarged pores
Dehydration
Dryness / flaking
Scarring / post-blemish marks

Sensitivity & Reactivity *

Fragrance sensitivity
Essential oils sensitivity
Active ingredient sensitivity (retinoids / acids / vitamin C)
Easily red / stings with products
Rosacea-prone
Eczema-prone

Skin History (Comment field) *

Do you have any known allergies? *

Yes (then explain below)
No

Explain *

Allergies / triggers (please list) *

Are you currently using any of the following? *

Retinoids (retinol / tretinoin)
Exfoliating acids (AHA/BHA)
Prescription acne treatment
Steroids / topical medicated creams
None

Pregnant or breastfeeding? *

Yes
No

SPF daily? *

Yes
Sometimes
No

How often do you exfoliate? *

Never
1× per week
2–3× per week
More often

Your main skin goal (next 4–8 weeks) *

Hydration & comfort
Clearer skin
Brighter tone
Firming & lines
Calm redness & sensitivity
Balanced routine (simple + effective)
Anything else we should know? (Write Below)

Message: *

Current Routine: *

Current cleanser:

Current moisturiser:

Current serum/actives :

Consent *

Consent Required
I confirm the information provided is accurate to the best of my knowledge.
Professional disclaimer Required
I understand this skin analysis supports cosmetic recommendations and does not replace medical advice.

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