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Yes or No *

Yes

No

Yes or No *

Yes

No

Have you had—or are you presently experiencing—any of these conditions?

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Epilepsy

Eczema

Scar Easily

Varicose Veins

Hormone Imbalance

HIV/AIDS

Diabetes

Hepatitis

Poor circulation

High/Low Blood Pressure

Any Active Infections

Fever blisters / cold sores

Skin diseases / skin lesions

Do you use or have you ever used any of the following in the past year?

Select any / all that apply

Accutane

Deferin

Glycolic Acid

Retin-A

Salicylic Acid

AHA

Renova

Adapalene Hydroxl Acid

Any Vitamin A-derived product (Accutane)

Have you ever experienced an allergic reaction to any of the following?

Select any / all that apply

Cosmetics

Sunscreens

Fragrance

Medicine

Food

Iodine

Shellfish

AHAs

Latex

Required *

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