Joel A. Sabean, M.D. Dermatology Center of Southern Maine

SKIN CARE

SELF-EVALUATION

Skin Care Self-Evaluation Form for Your Visit with Dr. Sabean

Print this form out and bring it with you to your appointment.

or

Click here for and Adobe .PDF version of this
form for a better printout.

This guide is designed to help you clearly identify your skin care needs so you can get the most out of a visit with Dr. Sabean. Just take a moment now to answer each question. A diagram has been included to chart your problem areas, so you and Doctor Sabean can determine how to keep your skin looking the best it can. Please bring this form with you to your appointment.

1. What do you like about your skin?

____________________________________________________________

2. What is your current skin care routine?
(Include cleansing, moisturizing, anti-aging creams, skin and sun care products, and anything else you use.)

Morning Routine:____________________________________________

____________________________________________________________

Nighttime Routine:___________________________________________

____________________________________________________________

3. How would you describe your skin type?

Oily

Dry

Combination

4. Do you use sunscreen?

	Every day		When I know I'll be outside a lot
	Occasionally		Never

5. Are you currently using an "anti-aging" cream or treatment?

Yes

5a. If "Yes," please list which one(s).

_____________________________________________________________

6. Check off what you believe are "problem" areas on your skin. (Check as many as applicable.)

	Fine lines/wrinkles		Smile lines
	Rough texture		Dark under-eye circles
	Brown spots		Uneven skin tone
	Breakouts		Sun damage
	Sagging skin		Other______________________

7. Using the key below, indicate your "problem" areas on the diagram below.


	Key:
	X - Fine lines/wrinkles
	S - Smile lines
	-- - Rough texture
	C - Dark under-eye circles
	B - Brown spots
	T - Uneven skin tone
	++ - Breakouts
	D - Sun damage
	// - Sagging skin
	O - Other

Write in any thoughts or questions you have here:
___________________________________________________________

___________________________________________________________