Name:

Age:

Gender: Female Male

Email:

What is your skin type? Oily Dry Combination Normal Sensitive

What are your main skin concerns? (Select all that apply) Acne Wrinkles Dryness Hyperpigmentation Blackheads/Whiteheads Large Pores Redness/Rosacea Fine Lines/Wrinkles Dullness Sensitivity

What products are you currently using and how often?

Describe your diet: Omnivore Pescatarian Vegetarian Vegan Gluten-Free Dairy-Free Paleo Keto Mediterranean Flexitarian

How many hours do you sleep on average? Less than 5 hours 5-7 hours More than 7 hours

Stress levels: Low Moderate High

Sun exposure (hours per day): Less than 1 hour 1-2 hours More than 2 hours

Any allergies, medications, or existing skin conditions?

Desired outcome: Improved overall skin health Enhanced skin barrier function Reduced breakouts Minimized signs of aging Balanced sebum production Improved hydration Soothed and calmed skin Even skin tone

Budget for skincare products and treatments: Less than $50 $50-$100 $100-$200 More than $200

Preferred product brands: Natural Organic Natural & Organic Cruelty-Free Vegan Luxury Drugstore Dermatologist-Recommended Open to All Brands

Any negative reactions or sensitivities with previous skincare products?