Longevity Clinic — Dermatology & Aesthetics
Skin & Hair Health
Epigenetic Assessment Form
Average completion time: 4–5 minutes · 25 questions
This form is designed to help prepare a more accurate, personalised interpretation of your skin and hair health genetic report. Your answers are reviewed by the clinician only and are not shared with third parties. You may skip questions that do not apply.
0
Identity
Basic patient information
1
Skin profile
Your current skin status
2
Ageing & elasticity
Collagen, elastin and aesthetic procedure history
3
Pigmentation & spots
Melasma, hyperpigmentation, solar lentigo
4
Skin barrier & product tolerance
Sensitivity, retinol, AHA/BHA tolerance
5
Hair health
Shedding, pattern, treatment history
6
Inflammation & reactivity
Acne, rosacea, wound healing
7
Nutrition & vitamins
Deficiencies, supplements, dietary pattern
8
General health
Chronic disease, medications, lifestyle
+
Stress & additional notes
Chronic stress directly affects skin and hair
5
0 — None10 — Very high
Your answers are reviewed by the clinician only.