Aesthetic Treatment Assessment
This questionnaire helps you discover the top treatment options providers may recommend for skin concerns like
acne, fine lines, or uneven tone—and matches you with the
most effective treatment options.
Help your skin look and feel its best.
How old are you?
20s
30s
40s
50s
60+
Which best describes your skin‐type?
Always Burns
Does Not Tan
(Fitzpatrick I)
Does Not Tan
(Fitzpatrick I)
Burns Easily
Tans Poorly
(Fitzpatrick II)
Tans Poorly
(Fitzpatrick II)
Tans After
Initial Burn
(Fitzpatrick III)
Initial Burn
(Fitzpatrick III)
Burns Minimally
Tans Easily
(Fitzpatrick IV)
Tans Easily
(Fitzpatrick IV)
Rarely Burns
Tans Darkly Easily
(Fitzpatrick V)
Tans Darkly Easily
(Fitzpatrick V)
Never Burns
Always Tans Darkly
(Fitzpatrick VI)
Always Tans Darkly
(Fitzpatrick VI)
Describe Your Skin (up to 2)
Normal
Oily
Dry
Combination
Sensitive
Tough
I am not sure
Select Your Concerns (select all that apply)
Texture
Sun damage & dark spots
Deep lines/wrinkles
Fine lines
Collagen loss
Lack-luster skin
Sagging/crepey Skin
Pores / pore size
Dark circles
Redness / rosacea
Red spots
Small blood vessels / spider veins
Active acne
Acne scarring
Other scars / surgical scars
Undesired hair growth
Thin lips
Hair loss
Weight gain
Spider veins
Lack of muscle
Stretch marks
None of the above
Where Are Your Concerns?
Face
Body
Do you experience any of the following symptoms? (select all that apply)
Fatigue/lack of energy
Difficulty sleeping or sleeping too much
Mood swings or irritability
Anxiety
Joint and/or muscle pain
Brain fog
Low libido
Hot flashes and/or night sweats
Difficulties with memory
Feeling cold frequently
Headaches and/or migraines
Weight gain
None of the above