SAT Skin Analysis Test

Personalized Skin Program Targets Your Needs & Goals

**Check off all that apply to you**
Name
Age		Male Female
Email
Phone
Your Heritage	African Asian Caucasian Native Indian
Skin Color	Pink White Yellow White Light Brown Olive Brown Black
When in Sun for 30 min.s, My Skin	Always Burns, Never Tans Sometimes Burns, but Tans Never Burns, Always Tans
Skin Conditions	Dry Normal Oily (T-zone) Acne Excessive Acne White Bumps Uneven Skin Tone Red Blotches Flaking (white) Scaling Patches (red) Visible Irritation Dark Circles Under Eyes Freckled Skin Photo Damage Brown Patches Brown Age Spots Rashes Hives Fine Skin (no visible pores) Visible Pores on Nose Visible Pores on Cheeks
Hair Type	Oily Hair Dry Hair
Other	Smoker
Fine Aging Lines	Eyes Nose to Mouth Lips Cheeks Neck Forehead
Medium Aging Lines	Eyes Nose to Mouth Lips Cheeks Neck Forehead
Saggy Skin	Under Eyes Eye Lids Cheeks Jaw Line Neck
Puffiness	Under Eyes Upper Eyelid Cheeks Jaw Line Neck
Current Doctor Diagnose(s)	Pregnancy Cancer Spots Lack of Skin Sensation Eczema Inflammation Skin Diseases Allergies to Fragrances Allergies to Medications Allergies to Plants Scar Tissue Face Couperose Rosacea Psoriasis
Do You Have	Cold Hands & Feet Wounds Heal Slowly Sleep Too Little Sleep Too Much Hot Flashes Spontaneous Sweating General Sense of Water Retention Throughout Body Pain in Lower Back Pain in Upper Back Pain in Joints Crave Salt Crave Sweets Sense of Well-being Seems to Fluctuate Throughout the Day for No Apparent Reason Fatigue Inability to Concentrate Numbness, Tingling or Prickly Skin Sensation Body Hair Thinning Outer 1/3" of Eye Brows Thinning or Gone Thick Brittle Nails Bruise Easily Watery Eyes Yellow Cast to Eyes Red Sticky Eye Lids Unexplained Itchy Skin Feel Nausea When You Eat Alternate Between Constipation & Diarrhea
Our Product Bases offer you an Exclusive Elegant Serum-Lotion or Cream that are both Highly Moisturizing. They absorb quickly, distribute evenly and have a silky, soft touch. You can change your base with seasonal change.
Choose Your Base	Serum-lotion Light hydrating base, penetrates well, best in humid, hot weather conditions, good under makeup & great for oily skin types, but suited for all skin types Cream Base is suited best for skin & weather conditions that are dry & need extra moisture, penetrates well, good under makeup

	Your answers will not be shared with anyone. Only Dr. Eric Gerken or Laurie Krause will evaluate your SAT.