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SKIN-Test
Name
Age
Gender
1. Male
2. Female
3. Prefer not to say
Phone
Skin Type
1. Oily
2. Dry
3. Combination
4. Normal
5. Sensitive
Skin Concerns (Select all that apply)
Acne / Breakouts
Dark spots / Pigmentation
Fine lines / Wrinkles
Uneven texture
Redness / Sensitivity
Dullness
Large pores
Dark circles
Dehydration
How many hours of sleep do you get daily?
Less than 5 hours
5–7 hours
7–9 hours
More than 9 hours
Water intake per day
Less than 1 litre
1–2 litres
More than 2 litres
Do you smoke?
Yes
No
Sometimes
Do you consume alcohol?
Frequently
Occasionally
Rarely
Never
Do you use sunscreen daily?
Yes
No
How often are you exposed to sunlight?
Rarely
1–2 hours/day
3–5 hours/day
More than 5 hours/day
Daily skincare steps you follow
Cleanser
Toner
Serum
Moisturizer
Sunscreen
None
Do you have any known skin allergies?
Have you undergone any dermatological treatment in the last 6 months?
Do you experience any of the following?
Redness
Burning sensation
Flakiness
Itching
None
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