Orthomolecular Facial Analysis Form

Your skin: (Please check any condition that applies)

Breakouts/acne

Blackheads/whiteheads

Excessive oil/shine

Milia

Cysts

Scars

Wrinkles

Dry/flaky skin

Dull skin

Uneven skin tone

Sun Damage

Dark spots

Sensitive/reactive skin

Itchy, irritated skin

Redness

Broken capillaries

Rosacea

Eczema

Puffiness

Bags under eyes

Dark circles around eyes

Melasma

Vitiligo

Skin Cancer

Cherry angiomas on body

Dandruff

Bruises easily

White spots on nails

Lines on nails

What are your skincare goals?

Have you had any of these problems in the past or present?

Are you allergic to:

Medicine (aspirin, etc.)

Food (dairy, gluten, eggs, etc.)

Outdoor allergens (pollen, etc.)

Indoor allergens (pet hair, mold, smoke, scents, etc.)

Household chemicals (cleaning products, etc.)

Latex or other materials

Copper or other metals

Miami Natural Skincare