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 scars Enlarged poresGreasy skinBlackheadsWhiteheadsWrinkles Overall 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 SkinNameSubmit
