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How old are you?................................................................................
Do you have any permanent facial brown spots or broken
blood vessels?...................................................................................
Yes
No
Are there noticeable lines around your eyes or lips?...................
Yes
No
Do you have deep creases on your forehead or cheeks?............
Yes
No
Did you or do you still tan, indoors or outdoors,
at least twice a week?
Yes, without sunscreen.....................................................................
Yes
No
Yes, with sunscreen...........................................................................
Yes
No
Has your face suffered at least three severe sunburns,
complete with peeling?......................................................................
Yes
No
Do you smoke?....................................................................................
Yes
No
Do you drink five or more beers, glasses of wine or
cocktails a week?................................................................................
Yes
No
Do you work out at least three times a week?................................
Yes
No
Do you munch on fruits and vegetables three or more
times a day?.........................................................................................
Yes
No
Do you use an SPF 15+ product each morning?.............................
Yes
No
Do you use antioxidants (Vitamin C, Vitamin E, etc.)
as a part of your daily routine?.........................................................
Yes
No
Do you use prescription lotions (such as tretinoin or hydroquinone) once or more than once a week?..........................
Yes
No
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