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FAQ

Free Skin Evaluation

Our skin care specialists are dedicated to helping you find the best treatment system for your skin!

Please print this quiz.

Complete all fields to the best of your ability.

Submit to us via fax: 1-786-245-8385 or email: SkinEvaluation@ViDermSkin.com.

Your quiz will be closely analyzed by a skin care specialist.

Your evaluation will come to you by email, so be sure to write your email address clearly.

(please allow up to 48 hours for your results)

First Name: ____________ Last Name: ____________ Email: _____________________ Phone:_________________ (optional)
Age Group: ______Teen’s ______20’s ______30’s ______40’s _______50’s _______60’s _______70+
______Male _______Female
Where do you live? Country _____________ State (if in the U.S) ___________
Do you live or work in an urban city? _______Yes _______No
Ethnicity: _______Caucasian _______Latin American _______African American _______Asian ______Hispanic _______Other
Rate your skin’s sensitivity: _______Very sensitive _______Mildly sensitive _______Normal _______Not sensitive at all
How would you describe your skin type? ________Oily ________Normal _________Dry ________Combination
Are you exposed to scatter radiation at your work? _______Yes _______No
How many hours per day are you exposed to the sun on average? _______Less than 30 minutes _______30minutes- 2hours _______More than 2 hours per day
How many times have you been to a tanning bed in your life? _______Never ________10+ ________20+ ________50+
Do you play golf? ________Yes _______No
Do you wear sunscreen of at least SPF 30 on a regular basis? _______Yes _______No
How many days of the month are you traveling? _______0-2 _______3-5 ______6-10 ________over 10
Are you diligent with your current skin care regimen? Or do you find yourself skipping steps? _______Diligent _______Skip steps
What is your average weekly alcohol consumption? _______I do not drink ______1-3 ________3-6 _______6-15 ______more than 15 ________I would rather not answer
How many 8oz. glasses of water do you drink per day? ______10-15 _______5-9 ________Less than 5
Do you eat at least 4 servings of fruits and vegetables per day? ______Yes _______No
Approximately how many grams of sugar do you consume per day? _______0-20 _______20-50 _______50-100 _______100+
Do you smoke? ______Never _______Occasionally (under 10 cigarettes per month) _______A little more than 10 per month ________1 or more packs per day _________I would rather not answer
What is your oral vitamin consumption regularity? _______Multi-Vitamin every day _______I try to remember ________When I am feeling run down ________I don’t take vitamins
Do you take oral contraceptives? _______Yes _______No _______I would rather not answer
Do you take other prescription medications on a regular basis? ________Yes ________No _________ I would rather not answer
Do you battle with acne? _______Not at all ________Mildly ________Very much ________I have a very severe case and nothing has worked in the past
Rate your overall level of stress: _______High ________Medium ________Low
How many hours of sleep do you get per night on average? _______8-10 hours ________6-8 hours ________Less than 6
Do you get at least 20 minutes of exercise 3 times per week? ________Yes _______No
Do you ever get Acne or Blemishes on your Back, Chest or Upper-Arms? __________Yes ___________No
Has the Skin on Your Body Lost its Shine? _______Yes ________No
Do you want the quickest and most effective results possible? _______Yes ________No
What do you expect your skin care to do?

a. Rebuild and Stimulate new Collagen and Elastin Formation