Name *

First Name

Last Name

Have you ever achieved the results you want? *

Yes

No

How does your skin feel after washing your face at the end of the day? *

Clear, slippery and a bit bumpy

Still oily on the nose but tight on my cheeks

So itchy that I must apply moisturizer

How would you describe your pores? *

They aren't really visible to the naked eye

Got some, but mostly on my beautiful nose

They are everywhere and I usually cover them

Do you get blackheads and pimples? *

Not really, rather occasional rashes

Sometimes, mostly on my chin & forehead

Unfortunately, all the time

How does your skin look after a workout? *

Red and greasy

Mostly the same

All patchy and red

Are you currently using or have used Accutane or Roaccutane in the past 2 years? *

Yes

No

Are you using Retin-A,, Tretinoin, AHA or any other peeling agents? *

Yes

No

Are you taking medications (over the counter, medication, supplements, vitamins, aspirin? *

Yes

No

Are you pregnant? *

Yes

No

Breastfeeding? *

Yes

No

Have you been under a physician's care in the past 3 years?  *

Yes

No

Have you seen a DMK Skin Revision Therapist? *

Yes

No

If yes, when was your last enzyme treatment? 

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