Skin Assessment Form

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Basic Information
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3. Age
0-10
11-24
25-49
Above 50
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6. How did you know about MAK4?
Friend/Family Member
Facebook
Website
Referral
Other
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7. What are your skin care goals?
Clear Skin
No Pimples
No Breakouts
No Dryness
Young Looking Skin
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Disturbed skin in young children is often caused by factors related to the genes they get from their parents or from infections of the skin. By the end of the assessment you will understand your child’s condition and what products to use.

Everyone can attain a clear skin and a younger looking skin if they consistently use the right products for their age group.

Break outs of pimples can be controlled if the right products are used. By the end of the assessment, you will understand why you get break outs and the products to use.

Dryness of skin at your age is commonly caused by aging and changes in hormones. The dryness can be prevented if you use the right products. By the end of the assessment, you will know the right products to use

8. What are your skin problems?
Itchy Skin with dryness
Blister like skin swellings with fluid
Pimples and pimple scars
Frequent breakouts with pimples
Increased sensitivity of skin ( itches when product is applied)
Dryness of skin
Fine lines & wrinkles
Dull skin
Skin rash in small round patches
Skin Rash
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  • It is normal to have increased pimples and frequent breakouts at your age. For most people, this goes on until 24 years.
  • The skin produces too much oil (sebum) which blocks the pores,
  • Germs mix with the oil and cause swelling, reddening and pain,
  • This causes the small bumps on skin, which appear as pimples,
  • This situation is because of the hormonal changes in your body.
  • However, the pimples can be controlled and the breakouts reduced, if you use the right products for your age group.

Frequent breakout of pimples and dryness of skin are not common at your age. The commonest cause of increased pimples, breakouts and dryness of skin in your age group is use of wrong products, especially those that block the pores or those that damage the skin. By the end of the assessment you will know the right products to use.

Dryness of skin at your age is caused by the aging process which leads to changes in hormones. If dry skin is not treated with the right products, it progresses to fine lines and wrinkles. The skin becomes dull because it accumulates dead cells. By the end of the assessment, you will know the right products to use.

White patches on the skin especially those on the face, body, upper arms, chest, might be fungal infections of the skin. By the end of the assessment you will understand the problem and the solution to it.

A rash on the skin which is uniform and not specific with distinct pimples or patches is commonly caused by use of wrong skin care products. By the end of the assessment, you will understand the right products to use on your skin

Please Note!

For the next set of questions, you will need to be truthful as you respond.
This is VERY IMPORTANT to get the right conclusion to the assessment and the right solution will be recommended for your specific problem.
Dishonesty makes it difficult to correlate some of the symptoms you might be presenting with and this might lead to recommendation of wrong products.
If you need any clarification, please call on our staff to help.

9. Have you used any products on your skin which changed your natural colour, however slight that change was (making it lighter)?
Yes
No
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If you are sure that you never used any product that changed your skin colour , however slight that change was, we shall now move ahead to confirm your skin type by going through the skin test. It takes only 2 minutes to complete the test.

10. Have you used creams or tubes from pharmacies to clear skin? Such as Betaderm, Skderm, MCG etc
Yes
No
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11. When did you use the creams or tubes from pharmacies to clear skin ? Such as Betaderm, Skderm, MCG etc
Currently using
Within the last 30 days
Three months back
Six or more months back
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12. Have you used creams mixed from different sources (bitabule) by individuals?
Yes
No
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13. When did you use creams mixed from different sources (bitabule) by individuals?
Currently using
Within the last 30 days
Three months back
Six or more months back
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14. Have you used any other branded skincare products that lighten skin?
Yes
No
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15. When did you use any other branded products that lighten skin?
Currently using
Within the last 30 days
Three months back
Six or more months back
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16. Does your skin become itchy, red, painful when you apply skincare products (sensitive) ?
Yes
No
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17. When did the problem in question 16 start?
Since childhood
In adulthood
Recently
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18. Do you have any allergies to foods ( dairy products, nuts, meat etc) , insects or perfumes?
Yes
No
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19. Skin Test

We shall now move ahead to confirm your skin type by going through a skin test. It takes only 2 minutes to complete the test.

Please respond according to what your skin was like before you used products that changed your skin colour. These include creams from pharmacies, mixed creams and branded skin lightening creams. We want to be sure of your natural skin type in order to choose the right products for you.

19(a). What is your age?
Below 24 years old
25 - 45 years old
46 - 60 years old
Over 60 years old
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19(b). How does your skin look like?
Does not really shine
Is dull and shows some flaking (dry patches)
Shines on the forehead and nose
Shines on the entire face
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19(c). How are your skin pores?
Not really noticeable
Large and visible on entire face
Large and visible on nose but not visible on cheeks
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19(d). How does your skin feel when touched?
Dry and thin
Oily on forehead and nose
Oily on entire face
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19(e). How often do you feel tightness around the eyes and mouth area?
Very often
Sometimes
Never
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19(f). How often do you have pimples?
Never
Sometimes
Very Often
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20. Is the skin of the child itchy, or do you see the child scratching the skin?
Yes
No
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21. Is the skin dry and scaly, most of the time?
Yes
No
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22. Which parts of the body are most affected with itching and dryness??
Face
Scalp
Abdomen
Neck
In front Of Elbows
Behind Knees
Hands
Feet
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23 (a). Does the itching of skin worsen with eating certain foods?
Yes
No
Not Sure
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23 (b) Does your skin look like what you see in the picture
Yes
No
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24. Does skin have blister- like swellings which turn into wounds with orange, brown crusts ?
Yes
No
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25. Does the skin have pimple-like swellings ?
Yes
No
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26. Do the swellings contain fluid or pus?
Yes
No
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27 (a). Are the swellings painful?
Yes
No
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27 (b). Does the skin look like what you see in the picture?
Yes
No
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28. Is the skin rash presenting as multiple white patches , paler than surrounding skin?
Yes
No
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29. Are the white patches flat and round, and in some places joined to form large areas?
Yes
No
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30. Is the skin rash presenting as multiple round patches with raised borders ?
Yes
No
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31. Do the round patches with raised borders have clear skin in the middle?
Yes
No
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32. Is the skin rash presenting as raised, round, oval, coin-sized plaques (raised above skin)?
Yes
No
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33. Did the plaques start as small lesions (rash or swellings) that joined to form the big plaques?
Yes
No
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34. Are the plaques distributed symmetrically ( both sides) on the scalp, face, knees, elbows , body folds?
Yes
No
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35. Do the plaques have grey or silvery-white dry scales?
Yes
No
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36. Do the plaques intensely itch or burn?
Yes
No
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We are going to show you a set of pictures, for you to select what looks closest to your problem

37. Choose the picture which looks closest to your problem
C
D
E
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Results from the Assessment
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Sensitive skin
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Package Price Products Action
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Chosen Package

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Would you like to learn more about lightening products?
Yes
No
What happens when one uses skin lightening creams that contain hydroquinone?

Skin creams with hydroquinone are mainly used to lighten skin. Hydroquinone causes the following problems on the skin and body.

  • Skin irritations presenting with a rash, itching, reddening.
  • Acne
  • Red or purple skin patches with a spidery or thread-like appearance
  • Blue-black discoloration of the skin
  • White patches
    • What happens when one uses skin lightening creams that contain mercury?

    Skin creams with mercury are mainly used to lighten skin. Mercury causes the following problems on the skin and body.

  • Painful fingers & toes.
  • Hands and Feet get a pink colour
  • Skin and Nails become darker