Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Q1. Check the following symptoms that you have experienced on your facial skin: RednessFlakingItchinessStingingSwellingPusScabsQ2. Key in the affected location on your face: (e.g around mouth, eyes etc)Q4. How many times in a month do you experience these symptoms? Q5. What was the duration of symptoms from the first time of observation?Q6. Do your skin symptoms come up because of a change in environment?YesNoQ7. Do your skin symptoms come up due to a change in skincare/makeup?YesNoQ8. Any known sensitivity/allergies to ingredients? What happens when you apply it?Q9. Do you dig and pick your skin? YesNoQ10. Are you bothered by any of the following?Acne scarsEnlarged poresGreasy skinBlackheadsWhiteheadsWrinklesOverall skin elasticity/firmnessSkin saggingOily skinRough/irregular texture of skinPimplesItchy bumpsQ11. On a scale of 0-10 (10 = most severely affected), how would you rate how affected you are by your symptoms? Q12. Do you have a family history of any of the following?AcneEczemaRosaceaQ13. Do you think your symptoms have worsened since wearing a face mask?YesNoQ14. What type of face mask are you currently wearing?Q15. Please choose your skin type:Combination SkinOily SkinDry SkinMessageSubmit