This guide is designed to help you clearly identify your skin care needs so you can get the most out of a visit with your dermatologist. Just take a moment now to answer each question. We've also included a diagram to chart your problem areas, so you and your doctor can determine how to keep your skin looking the best it can. Bring this form with you to your appointment.

1.  What do you like about your skin?

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2.  What is your current skin care routine?
(Include cleansing, moisturizing, anti-aging creams, skin and sun care products, and anything else you use.)

Morning Routine:
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Nighttime Routine:
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3.  How would you describe your skin type?

Oily

Dry

Combination

 4.  Do you use sunscreen?

	Every day		When I know I'll be outside a lot
	Occasionally		Never

5.  Are you currently using an "anti-aging" cream or treatment?

Yes

No

5a.  If "Yes," please list which one(s).

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6.  Check off what you believe are "problem" areas on your skin. (Check as many as applicable.)

	Fine lines/wrinkles		Smile lines
	Rough texture		Dark undereye circles
	Brown spots		Uneven skin tone
	Breakouts		Sun damage
	Sagging skin		Other______________________________________

7.  Using the key below, indicate your "problem" areas on the diagram below.

	Key:
	X - Fine lines/wrinkles
	S - Smile lines
	-- - Rough texture
	C - Dark undereye circles
	B - Brown spots
	T - Uneven skin tone
	++ - Breakouts
	D - Sun damage
	// - Sagging skin
	O - Other

  

Write in any thoughts or questions you have here:

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Questions to ask your dermatologist or doctor:

• What's the best skin care regimen for me?

• Can anything make wrinkles disappear?

• What's the difference between prescription creams and over-the-counter products?

• Am I a candidate for laser surgery?

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