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DEMOGRAPHICS

MY PERSONAL DETAILS

This information allow Dermal Health Science to track your progress and provide you with the best advice and insight.





* Please enter your date of birth.

DEMOGRAPHICS

MY GENDER




male
male
female
female
other
other


* Please select your gender.

WHEN NOT EXPOSED TO THE SUN

MY NATURAL SKIN COLOR IS




pale-white
pale-white
white
white
light-brown
medium-brown
medium-brown
dark-brown
dark-brown
black
black
pale-white
pale-white
white
white
light-brown
light-brown
medium-brown
medium-brown
dark-brown
dark-brown
black
black


* Please select your skin color.

WITH NO CONTACT LENSES

MY NATURAL EYE COLOR IS




blue
blue
grey
grey
green
green
hazel
hazel
brown
brown
black
black
blue
blue
grey
grey
green
green
hazel
hazel
brown
brown
black
black


* Please select your eye color.

WITH NO ARTIFICIAL COLORANT

MY NATURAL HAIR COLOR IS




Hair Skin Brows Eyes
red
Hair Skin Brows Eyes
light-blonde
Hair Skin Brows Eyes
medium-blonde
Hair Skin Brows Eyes
light-brown
Hair Skin Brows Eyes
medium-brown
Hair Skin Brows Eyes
dark-brown
Hair Skin Brows Eyes
black
Hair Skin Brows Eyes
red
Hair Skin Brows Eyes
light-blonde
Hair Skin Brows Eyes
medium-blonde
Hair Skin Brows Eyes
light-brown
Hair Skin Brows Eyes
medium-brown
Hair Skin Brows Eyes
dark-brown
Hair Skin Brows Eyes
black


* Please select your hair color.

MEDICAL BACKGROUND

ACNE / BREAKOUTS HISTORY


I have used or currently use treatments for pimples

* This field is required.

MEDICAL BACKGROUND

ACNE MEDICATION HISTORY


The treatments I'm using or have used are

Over the counter products:

Topical creams or gels:

Prescription products:

Topical Antibiotics:


Oral Antibiotics:


Oral Retinoid or Vitamin A derivatives:

MEDICAL BACKGROUND

GYNECOLOGICAL HISTORY



I am pregnant



* This field is required.




DEMOGRAPHICS TABLE


Name Age Gender Skin Color Eye Color Hair Color



MEDICAL INFORMATION TABLE


Acne History Age Gender Skin Color Eye Color Hair Color