Product Suggestion Questionnaire
Please fill out the questionnaire below. Then click "Get Product Suggestions". Receive $5 off with your first order of $25 or more! Orders of $100 or more qualify for a 10% discount AND free shipping! Make sure you "Submit My Profile" so that we receive your full name and email address in order to credit your account (Shopping Cart will not calculate your discount).

Name:
Email:
State:   Country:

Sex:
Female
Male
 Marital status:
Married
Single
 Age:

Skin Care Information

1. My basic skin type is:
Normal
Oily
Dry

Mature (My skin is dry, thin and has some wrinkles)
Problematic (My skin breaks out frequently)

2. My breakouts usually are:
Blackheads
Whiteheads
Acne
N/A
3. My pore size is:
Small
Medium
Large

4. I experience flakiness or ashiness:
In patches
All over
N/A

 5. My skin has wrinkles in the following areas:
Eye area
Lip area
Forehead
All over
None
6. I currently suffer from:
Eczema
Rosaceae
Psoriasis
Other skin condition:

 7. My skin is sensitive to:
Synthetics
Fragrances
IP Alcohol
Other chemical sensitivities:

 8. I have a reaction to:
Commercial perfumes
Household products
Other fragrance allergies:

Personal Care Questionnaire
9. Which do you prefer
as a facial cleanser?
Cream
Lotion
Complexion bar
Loofa Disk
Salt Scrub
10. Which face care products do you use regularly?
Toner
Mask
Mosturizer
Eye cream

11. Do you use any special facial treatments, such as:
Antioxidants
Alpha-hydoxy
Collagen
Retin-A

12. Have you ever used a natural deodorant (one without aluminum compounds)?
Yes
No

 13. Do you use any natural foot care products?
Yes
No
 14. Do you use any natural hand care products?
Yes
No


I have other concerns about my skin (explain):

Kelly-Nehemiah Cosmetics Total Body Experience. Premium eco-holistic personal care.
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Tel: 206 427 2111. E-mail: merceris@juno.com
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