DayBreak Lavender Farm, herbal soaps, all-natural, handcrafted, & organic, pure spa treatments, garden-fresh toiletries
YOU WILL HAVE BEAUTIFUL SKIN ... NATURALLY
I want to create the perfect skin care regimen for your complexion. In order to better understand your complexion care needs, please fill in the Skin Care Profile Consultation below. It will take less than 5 minutes. All information in this Profile is strictly confidential. Just between you and me. Rest assured, here at DayBreak, we hold your privacy in the same high regard we hold our own. The information you provide is completely confidential and used only for analysis.

Once you have completed your profile, please allow two business days for me to receive, interpret and create your Perfect Skin Care Regimen to you via email. Thank you for your time and your support of DayBreak's Mission ... farm-crafted, natural, sustainable beauty!

Name: First, Last
Street
City
State Zip
Age
Please enter your numeric age. This is vital info and highly relevant to your skin condition. I'll never tell, I promise!!
Have you ever ordered any
DayBreak soaps, toiletries
or spa treatments?




Female Male
Yes No
How did you hear
about DayBreak?
Do You Work With A DayBreak PCT? Yes No
If So, What Is Her Name?
DayBreak Forum Name
Email
Email (again)
Day Phone
Evening Phone
Cell Phone





RELATIVES' COUNTRY OF ORIGIN
Please do not write U.S. or American in the country of origin question. Skin thickness, type and wrinkle rate are determined — to some extent — by your family's geographic roots so it's helpful to know if your grandparents were Swedish, Argentinian, Moroccan, African etc.
Skin type and thickness are a nifty combo of genetics and geography so please tell me where your relatives/grandparents roots were.

Please specify a country not a continent. Your Heritage Skin Type© is genetic so it's important that I understand where your skin's characteristics came from.

Your Maternal Grandmother
Your Maternal Grandfather
Your Paternal Grandmother
Your Paternal Grandfather
Please specify a country, not Europe or Asia.
Please do not write USA or America.
Please list a country not a state. Ohio is not a country of origin.
WORK ENVIRONMENT
What is your job?
What is your job title?
How many hours a week are you at work?
Is your work home-based? Yes No
Is your work environment:
High Stress
Medium Stress
Low Stress
Frequent Periods of High Stress with Down Time In Between
HOME ENVIRONMENT
I am:
Single
Married
Divorced
Widow/Widower
Stay at home mom with children.
WOMEN ONLY
Are you taking oral contraception? Yes No
Are you pregnant? Yes No
Are you trying to become pregnant? Yes No
Are you breast feeding? Yes No
Many folks are surprised to learn that acne is genetic. Tell us your breakout background.
My mother had breakouts on her Face
Chest
Back
Thighs
My father had breakouts on his Face
Chest
Back
Thighs
Do you ever experience irritation from shaving? Yes No
Do you experience ingrown hairs? Yes No
YOUR SKIN PROFILE
Skin Color
Most complexions vary in skin color. Choose the color that is the predominant shade of your face and neck.
WHITE PALE
WHITE/PINK
WHITE/PEACH
PINK (BLUE/RED UNDERTONE)
PEACH (GOLD/YELLOW UNDERTONE)
OLIVE (GOLD/GREEN UNDERTONE)
LIGHT BROWN
MEDIUM BROWN
DARK BROWN
DARKEST BROWN (WITH BLUE/BLACK UNDERTONE)
Skin Classification?
Check all that apply.
ACNE ADULT ONSET
ACNE ON THE BACK, CHEST
ACNE CHRONIC
ACNE CYSTIC
ACNE ROSACEA
ACNE VULGARIS
ACTIVE BREAKOUTS/LARGE PORES
AGING
BLACKHEADS (COMEDONES)
COUPEROSE (BROKEN CAPILLARIES)
DEEP LINES
DEHYDRATED
DISCOLORATIONS
DRY
FINE LINES
FINE TEXT, SMALL PORES
GOOD ELASTICITY
HYPER-PIGMENTATION
INGROWN HAIR
LOSS OF PIGMENT
MEDIUM TEXTURE/SMALL PORES
MELASMA
NEW ACNE SCARS
NORMAL
OILY
OLD ACNE SCARS
OLD BREAKOUTS/LARGE PORES
OPEN PORES
RELAXED ELASTICITY
SENSITIVE
SKIN BUMPS
SUPERFICIAL LINES
SUN DAMAGE
SUN/LIVER SPOTS
THIN
VITILIGO (DEPIGMENTATION)
WHITEHEADS (MILIUM)
WRINKLES
OTHER
What time of day do you first notice oil?
15 to 30 minutes after cleansing
Midmorning 9 to 10 am
Lunch time 12 pm
Midafternoon 2 to 3 pm
Late Day 4 to 5 pm
Totally Dry
I do not experience breakthrough oily shine during the day
Do you experience skin break-outs? Yes No
Skin Tone? VERY LOOSE
LOOSE
SLIGHT FOLDS AT JOWLS
MEDIUM
FIRM
What aspect of your complexion are you most concerned about?
ACNE MILD
ACNE MODERATE
ACNE SEVERE
APPEARANCE OF FINE LINES & WRINKLES
DRY
DRY/RED
EXTRA OILY
NORMAL
NORMAL/OILY T-ZONE
OILY
ROSACEA/OILY
Explain your skin care goals to me here.
Please complete this section; it's important in your analysis.
SKIN CARE
What water temperature do you cleanse with? Cool Warm Hot
Which DayBreak products are you currently using?
What types of cleansers are you now using?
Soap
Cleanser
Lotion
Cream
Are you currently using bar soap to cleanse your face? Yes No
Do you use any skin care products which contain mineral oil, lanolin, alcohol, color, fragrance, or formaldehyde? Yes No
How many times a day do you wash your face? Once Twice More Other
Reason why you wash more than once or twice daily?
Exfoliation Preference? STRONG
AVERAGE
LIGHT
NONE
FIRM
MAKEUP
What type of make-up do you use? Powder
Liquid
Mineral
None
How does your skin feel in the A.M. hours with make-up?
Without make-up?
When do you wear sunscreen? Daily
While Tanning Only
Only On Vacation
Never
What strength SPF do you normally wear?
Is your SPF in your make-up? Yes No
If yes, what product?
EYE COLOR
What is your eye color? BROWN
BLUE
GREEN
HAZEL
OTHER
HAIR
Natural Color BROWN
BLACK
DARK BLONDE
MEDIUM/LT BLONDE
RED
GRAY
WHITE
Texture FINE
MEDIUM
COARSE
Density THIN
AVERAGE
THICK
Scalp DRY/FLAKY
OILY
SENSITIVE
NORMAL
Chemical Treatments COLOR
PERM
STRAIGHTENING/RELAXING
What is your hair's most annoying characteristic?
DIET
Are you currently on a restricted diet? Yes No
How much plain water do you consume daily?
1-2 cups
3-4 cups
5-6 cups
7+ cups
Briefly describe your eating patterns:
Do you currently take vitamin supplements? Yes No
If so, please describe:
Do you currently take any mineral supplements? Yes No
If so, please describe:
Do you currently take any enzyme supplements? Yes No
If so, please describe:
Do you currently take any antioxidant supplements? Yes No
Have you had general anesthesia in the last 12 months? Yes No
Do you smoke? Yes No
EXERCISE
Do you exercise regularly? Yes No
How many hours do you spend outdoors weekly?
Do you notice a change in your skin with changes in seasons or the weather? Yes No
Does your skin react to any of the following? Heat? Cold? Wind? If yes, how?
Do you use any of these? Tanning Beds?
Sunbathe?
Mystic Tan?
Fake and Bake?
No
If so, how often?
MEDICAL HISTORY
Are you susceptible to cold sores? Yes No
Which of the following cause flare-ups? Sun
Stress
Exercise
Menstrual
Food >
Other >
Are you currently under the care of a dermatologist or esthetician? Yes No
Do they currently have you on a treatment program? Yes No
If so, please describe
Are you taking any of these?
Azelex
Differin
Renova
Retin-A
Tazarac
Metrogel
Alphahydroxy Acids
Hormones
Birth Control
No
Antibiotics
Antibiotic details
Benzoyl Peroxide Treatments
Is it a BP Facial Wash, Cream, or Other (please describe)
Cosmetic Botox
Date Started and Number of Treatments
RETIN A DETAILS & ACCUTANE DETAILS
If you selected Retin A in the previous question, please provide more detail here.
What do you use it for? Acne Fine Lines
Do you have irritation, sensitivity, flaking from Retin A use? Yes No
Are you now using the Acne drug Accutane? Yes No
If no, have you used Accutane in the past? Yes No
If you used it in the past, how long ago?
Have you used glycolic? Yes No Don't Know
If you've used glycolic, what percentage? %
Do you have allergies or sensitivities to any of the following?
Alpha Hydroxyacids
Beta Hydroxyacids
Aspirin
Clindamycin
Fragrances
Hay fever/Seasonal Allergies
Hydrogen Peroxide
Hydroquinone
Latex
Nuts
Penicillin
Retin-A
Talc
No allergies to any of the above
Other allergies or sensitivities to typical skin care ingredients? Please list.
SCENT PREFERENCE
Scent Preference? FLORAL
HERBAL
SPICE
Favorite Perfume?
Is there anything you would like to tell me that I haven't asked?
Now that was quick and easy, wasn't it?
You're on your way to beautiful skin ... naturally!
Enter the code as it is shown (required):
By submitting this form, I acknowledge that I have read and understand the following. This questionnaire submitted online cannot substitute for the completeness of an in-person consultation with licensed professional skin care estheticians or doctors. I will analyze your skintype and suggest products based on the completeness and accuracy of the information provided by you.