Multi Step Form
1

Our body & its patterns

2

Diet & supplements

3

Rest & Recovery

4

Pollutants & climate

5

Skincare routine

6

Connection to self & others

7

Result

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What is your gender?

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What is your age?

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What is your skin type?

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Is your skin sensitive? Does it easily react to products and other factors and become irritated and red?

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How would you describe the current level of acne you are experiencing?

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Where on your body are you typically experiencing acne. Tick all the applies

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Are you experiencing your menstrual cycle at this stage in life?

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Have you noticed any negative changes to your skin while being pregnant?

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Is your menstruation typically following a regular pattern?

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Do you typically notice a connection between you menstrual cycle and the status of your skin?

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Do you currently take any hormonal medications or supplements?

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Do your close relatives have similar skin profile and skin concerns as you do?

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What is your current weight (in kg)

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What is your height (in cm)

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Have you lost or gained a lot of weight lately?

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Have you been diagnosed with any chronic health conditions, such as diabetes, heart disease, hypertension, asthma, cancer etc?

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Do you experience a link between certain food intake and the status of your skin and acne?

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How often do you eat a variety of colorful fruits and vegetables?

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How often do you eat foods rich in Omega-3 fatty acids, like fatty fish (like salmon, mackerel, tilapia, galunggong) and certain nuts and seeds (like flaxseeds, chia seeds, walnuts)?

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Are you including any nuts and seeds in your diet, like almonds, peanuts, hazelnuts, pine nuts, sunflower seeds etc?

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How often do you consume processed foods (like cereals, canned soups, ready-to-eat meals), fast food (like burgers, pizza, fried chicken) and quick carbs (like white bread and pasta)?

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How often do you consume sugary snacks and drinks (like candy, cookies, cakes, pastries, ice cream, soda and energy drinks)?

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What is your daily dairy intake (cow's milk)?

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How many cups of coffee or other caffeinated drinks (like tea, energy drinks, coke etc) have you been drinking per day during last few weeks?

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How many glasses of alcohol have you been drinking per week, in the last 4-6 weeks?

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What is your current routine when it comes to nutritional supplements?

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What has been your stress level during last few months?

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Have your emotional state and overall stress level changed over the last year?

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On average, how many hours of sleep do you get per night?

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How would you describe your sleep patterns and quality?

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How would you describe how you feel after waking up and your energy levels throughout the day?

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How often do you engage in relaxation or stress-reducing activities such as yoga, meditation, reading, singing, spending time in nature, or any other activity that helps you unwind?

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How often do you engage in moderate- or high-intensity physical activity, such as brisk walking, running, cycling, or swimming, where you feel your heart rate noticeably increase?

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Do you live in an area with lots of sun, where the UV index is frequently above 3 during daytime? Tip: If you're not sure, check the weather app on your phone.

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When you're outdoors on a sunny day, how do you typically approach sun exposure?

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How often do you typically wear sunscreen?

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Do you live in an area with high levels of air pollution?
Tip: If you're not sure, check the weather app on your phone.

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Do you currently smoke cigarettes or use any other form of tobacco?

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Which of the following best describes your typical daily skincare routine ?

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How much money would you typicall spend on skincare products each month?

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Which of these brands do you use on a regular basis?
Tick all that apply

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How often do you change the products in your skincare routine?

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When you experience acne breakouts, how often do you find yourself picking or squeezing the pimples?

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Do you incorporate facial massage or face yoga into your skincare routine?

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How much do you enjoy your daily skincare routine?

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Do you make sure to practice good hygiene habits for healthy skin, such as:
* Washing pillowcases weekly?
* Cleaning makeup brushes and sponges regularly?
* Cleaning your phone case regularly?
* Avoiding touching your face throughout the day?
* Keeping hair away from your face?

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Have you recently experiences any of these negative emotions: anger, deep frustration, sadness, fear, deep worry, anxiety, loneliness, grief?

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Do you feel that you get good support from family and friends, when meeting challenges in life?

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At present, how happy are you with appearance and feel of your skin

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Name

Gender

Female

Age

19-35

your body
& cycle

Diet
& Supplements

Rest
& Recovery

Pollutants
& climate

Your
skincare routine

Social
connectivity