Skin Care Survey
for Presentation

 This form is available in
downloadable Microsoft Word format,
with 4 forms laid out on an 8.5" x 11
sheet of paper.  Print it out and cut it up.]

NAME: _________________________________________________

ADDRESS: _____________________________________________

CITY: ________________ STATE: __________  ZIP:____________

PHONE (H): ____________________  (W):____________________

1.Are you currently using skin care products?  Yes (  )  No (  )

2. What skin care products are you currently using?
________________________________________________________

3. What do you like best and least about what you are using?
________________________________________________________

4. What are your most pressing skin concerns?
Chronic blemishes (  )
Blackheads (  )
Whiteheads (  )
Large Pores (  )
Oil breakthrough during the day  (  )
Brown discoloration (  )
Rough texture (  )
Redness (  )
Dryness (  )
Fine lines and wrinkles (  )
Flakiness (  )
Uneven skin tone (  )
Sagginess (  )
Sensitivity (  )
Puffy eyes (  )
Dark circles (  )

5. If you were given a three-day complimentary skin care sample would you be willing to use it exclusively for a three-day period?  Yes (  )  No (  )

6. After using it for three days would you be willing to give us your
opinion of the sample?  Yes (  )  No (  )

7.  If you fall in love with these products, would you be willing to host an anti-aging seminar?  Yes (  )  No (  )