Cosmetic Dermatology Self-Assessment

With respect to signs of agin, please rate the areas of the face that concern you most.

Using the buttons below, please rate these areas on a scale of 0 to 5 (0 being the least concern and 5 being most concern. Once you have completed the questionnaire you can print the results page and hand it to your doctor, or nurse. Your answers are completely confidential and are not recorded.

If any of these symptoms apply to you, you may want to consult with one of our health care providers. The results of this self assessment quiz are not to be considered as medical advice or diagnoses.

Anatomic Representation Score
Select one button for each category
Forehead 0 1 2 3 4 5
Crow's feet 0 1 2 3 4 5
Dark circles 0 1 2 3 4 5
Marionette lines/Smile lines 0 1 2 3 4 5
Verticle lip lines (smokers' lines) 0 1 2 3 4 5
Freckles / Age spots / Pigmentation 0 1 2 3 4 5
Frown Lines 0 1 2 3 4 5
Nose-to-mouth lines 0 1 2 3 4 5
Facial Blood vessels 0 1 2 3 4 5
Large pores, poor skin texture & fine lines 0 1 2 3 4 5

Contact Dr. L.A. Torres Jr.
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Our Services
Dr. L.A. Torres Jr. M.D.
4601 Old Shepard Pl.
Building One, Suite 101
Plano, Texas 75093

Phone: 214-919-2350
Fax: 214-919-2361