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Find your Customized
Solution
:
Blend & Boost® Consultation
In just a few minutes, this skin evaluation questionnaire will help your healthcare professional determine the perfect
Blend & Boost® product for your skin.
Date of birth
Month
January
February
March
April
May
June
July
August
September
October
November
December
Shipping Method
Direct to Clinic
Patient's Home
Pickup at Pharmacy
Select your
skin type:
Very Dry
Dry
Normal
Combination
Oily
Very Oily
What is your
primary
skin concern?
Aging
Post-procedure recovery
Moisture
Sensitivity
Oily skin and/or Blemishes
What is your
secondary
skin concern?
Aging
Post-procedure recovery
Moisture
Sensitivity
Oily skin and/or Blemishes
No secondary concern
What is your
most recent cosmetic procedure?
Botox
®
, Xeomin
®
, Dysport
®
Fillers
Laser (IPL, LG, Photo-rejuvenation)
Other
No Procedure
What is your
primary
skin aging concern?
Wrinkles
Instant wrinkle filling
Sun damage
Dark spots
Excess oil; blemishes
Redness
General sensitivity
How invasive was your
most recent cosmetic procedure?
Moderately invasive:
Recovery time is less than 1 day.
For example: Chemical peels, micro-dermabrasion, micro-needling, IPL, photo-rejuvenation
Highly invasive:
Recovery time is more than 1 day.
For example: resurfacing lasers, invasive treatments
What is your
primary
skin moisture concern?
Dehydration
Dryness
Excess oil; Blemishes
Wrinkles
Do you
experience any of the conditions below?
Rosacea/Couperose
Eczema (on the face)
None of the above
What is your
primary
skin sensitivity concern?
General sensitivity
Persistent redness
Itchiness, dryness
Excess of oil, blemishes
Wrinkles
Sun damage
What is your
primary
oily skin concern?
Excess of oil, blemishes
Hyperpigmentation and/or scarring
Sensitivity and/or redness
Wrinkles
Instant wrinkle filling
Do you have any
allergies and/or intolerances?
(more than one can be selected)
I do not have any allergies
Peanuts
Tree nuts
Dairy
Gluten
Other:
Do you currently use any
of the products below?
Soap / Cleanser
Facial Moisturizer / Serum
Facial sunscreen
I do not use any of these products
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Disclaimer: This questionnaire may contain references to various skin conditions. This is solely for the purpose of designing a cosmetic specific to your skin type and treatment history, and not for medical treatment of the skin condition. Product and ingredient recommendations are for cosmetic purposes and are not intended, nor should they be considered, a drug treatment or therapeutic regimen.
Which photo
best corresponds to your condition?
WRINKLE GRADE 1
WRINKLE GRADE 2
WRINKLE GRADE 3
WRINKLE GRADE 4
1
2
3
4
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X
Which photo
best corresponds to your condition?
INSTANT WRINKLE
FILLING GRADE 1
INSTANT WRINKLE
FILLING GRADE 2
INSTANT WRINKLE
FILLING GRADE 3
INSTANT WRINKLE
FILLING GRADE 4
1
2
3
4
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Instant Wrinkle Filling: instant wrinkle volumizing effect
X
Select the
intensity of your condition.
Mild
Moderate
Significant
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Dark Spots: Freckles, brown spots, uneven skin tone, melasma
X
Select the
intensity of your condition.
Mild
Moderate
Significant
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Sun Damage: Premature aging caused by repeated exposure to UV rays (sun or artificial sources). This can result in sun spots, uneven tone, fine lines, skin roughness, dehydration and/or redness.
X
Please enter your address information.
Address:
City:
Zip / Postal Code:
State / Province:
Country:
Let's get started!
Enter your
phone number
to be contacted by your Blend & Boost® professional.
-
-
Enter your
email address
if you wish to receive your summary after the questionnaire.
You must enter a valid e-mail address
Select the
intensity of your condition.
Mild to Moderate
Moderate to Significant
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Dryness: Your skin lacks oils: flaking of skin surface (desquamation), cracking, discomfort
X
Select the
intensity of your condition.
Mild to Moderate
Moderate to Significant
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Rosacea: Frequent flushing or blushing on cheeks, nose, chin, forehead. Persistent redness. Visible red lines due to enlarged blood vessels. Tingling, burning
X
Select the
intensity of your condition.
Mild to Moderate
Moderate to Significant
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Eczema: Inflammed or eczematous skin is red, itchy and swollen sometimes with fluid-filled bumps that ooze and crust
X
Select the
intensity of your condition.
Mild to Moderate
Moderate to Significant
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General Sensitivity: Sensitive skin is excessively reactive and fragile. It manifests with tingling, tightness, redness and itchiness for example
X
Select the
intensity of your condition.
Mild to Moderate
Moderate to Significant
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Itchiness and Dryness: Itching sensation, flaking of skin surface (desquamation), discomfort
X
Select the
intensity of your condition.
Mild to Moderate
Moderate to Significant
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Sensitivity and/or Redness: Skin is excessively reactive and fragile: tingling, burning and redness
X
Which description
best corresponds to your condition?
CONDITION 1
CONDITION 2
CONDITION 3
Shiny Skin, Large Pores
Condition 1 + Whiteheads / Blackheads
Condition 2 + Inflamed Pimples
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X
X
YOUR SKIN. YOUR
Solution
YOUR CONSULTATION SUMMARY:
Jane Doe
Date of birth: MONTH/DAY/YEAR
Phone number
Your skin type
1
st
skin concern
2
nd
skin concern
Combination
Your most recent procedure:
Your 1
st
Your 2
nd
Your 3
rd
Your most recent procedure:
Your 1
st
Your 2
nd
Your 3
rd
DISCLAIMER: Blend & Boost® is not a replacement for cosmetic procedures or medicated products. The information contained herein is strictly for use by the healthcare professional and patient. It contains personal information protected by doctor patient confidentiality. Any dissemination, distribution or copying of the content of this document is prohibited.
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skin evaluation
questionnaire has been sent
to your
healthcare professional
.
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Solution
!
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