Blissoma Skin Evaluation
Thank you for contacting us to request a holistic skin consultation! We have been providing in-depth assistance to our customers for years, and helping you achieve healthy skin is our passion. We are honored you have chosen to reach out to us.

Please take the initial intake questionnaire below. It will help us to have a more effective dialogue about your skin and needs.

All your answers are kept confidential to protect your privacy. Please do answer honestly and thoroughly so that we will have the most complete information to be able to help you. Some questions are optional.

Let's create healthy, beautiful skin together!

Email address *
What is your name? *
Your answer
What is your age range? *
Where do you live? *
Your answer
What is your skin color?
What are your current goals for your skin and what would you like to achieve by working with us? *
Your answer
Are you currently using any Blissoma skincare products? If so please list which products you are using and how you feel they are working for your skin.
Your answer
Please select all statements that apply to describing your skin's oil production and hydration level. *
Required
Do you have any of these common issues? Check all that apply.
Do you have any known allergies or sensitivities to common skincare ingredients? If so which ones? *
Your answer
Do you have any dietary or internally based allergies or sensitivities to foods or pollen? If so what are they? *
Your answer
What problems (if any) are you currently looking to address in your skincare routine?
Your answer
What is your current morning skincare routine? *
Your answer
What is your current evening skincare routine? *
Your answer
What brand of products are you currently using and have you been happy with them? *
Your answer
Do you have any problems using essential oils in skincare? *
Your answer
How does your skin react to coconut oil? *
How much time do you spend in the sun? *
Do you currently use a sunscreen product on your face, and how often? Is it mineral or chemical based? Please list the brand.
Your answer
Please describe the foods you commonly eat.
Your answer
Do you currently follow any dietary restrictions?
Your answer
Do you notice changes in your skin from winter to summer besides getting a little darker or lighter from sun?
Your answer
For acne sufferers: Do you notice breakouts from any particular triggers? Check all that you feel apply.
For acne: How often do you break out?
For acne: Please select the type of breakouts you get. Check all that apply.
For acne: Where do your breakouts occur on the face? Check all that apply.
For skin allergies: Please describe what happens when you react to something. Check all that apply.
Do you experience redness or extreme flushing in your face at times?
Please list any current health issues you are addressing at this time that you feel comfortable sharing with us. Your answers will be kept private to Blissoma staff.
Your answer
Are you taking any prescription medications? Please list whatever you feel comfortable sharing with us. Your answers will be kept private to Blissoma staff.
Your answer
Have you ever been officially diagnosed with a skin disorder by a dermatologist? *
Your answer
What kind of services have you gotten from other skin professionals so far and what were the results? *
Your answer
Is your skin currently irritated? Please describe the quality and duration of your skin disruption if so.
Your answer
Do you currently use makeup on a routine basis? Please list the brands of products in your current routine if so.
Your answer
Would you also like recommendations for natural makeup products to go with your skin? If so which types of products?
Your answer
Please select the statements that best describe your use of green beauty products. *
Required
Is there anything we have not asked about that you would like to share with us?
Your answer
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