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Beauty and skincare · Form

Sample پرسشنامه‌ی مشاوره‌ی پوست

پیش از مراجعه به کلینیک: نوع پوست، نگرانی‌ها، سابقه‌ی حساسیت و داروهای مصرفی.

10 questions · Free up to 50 responses a month

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About this template

“پرسشنامه‌ی مشاوره‌ی پوست” has 10 questions on 2 pages; 6 are required and 4 optional. Question types: Yes / No (2), Long text (2), Short text (1), Mobile number (1), Number (1), Single choice (1), Multiple choice (1), File upload (1). Its sections, in order: «پوست شما», «سابقه». 10 ready-made options across 2 choice questions, all editable in the online version.

In the online version of this template

  • Mobile numbers are validated against the Iranian number format.
  • Attached files are stored with the response.
Related:Online form builder

پوست شما

  1. 1.

    نام و نام خانوادگی *

    (Short text)
  2. 2.

    شماره موبایل *

    (Mobile number)
  3. 3.

    سن *

    (Number)
  4. 4.

    نوع پوست *

    (Single choice)
    • خشک
    • چرب
    • مختلط
    • حساس
    • نمی‌دانم
  5. 5.

    نگرانی اصلی *

    (Multiple choice)
    • جوش
    • لک
    • چروک
    • منافذ باز
    • قرمزی

سابقه

  1. 6.

    سابقه‌ی حساسیت دارویی یا آرایشی دارید؟ *

    (Yes / No)
  2. 7.

    به چه چیزی؟

    (Long text)
  3. 8.

    باردار یا شیرده هستید؟

    (Yes / No)
  4. 9.

    داروهای مصرفی فعلی

    (Long text)
  5. 10.

    عکس ناحیه‌ی مورد نظر (اختیاری)

    (File upload)

Printable or online?

Printable version (Word & PDF)

  • For filling in on paper, signing and filing by hand
  • Edit the Word file any way you like
  • Collecting and typing up the answers is up to you
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Online version on Porsino

  • Answers are collected and organised automatically — no retyping
  • National ID, mobile number and dates are validated instantly
  • Ready-made reports and charts, plus Excel export in one click
  • Share a link or QR code — it works on mobile too
Build the online version for free

How do I use this template?

  1. Sign up for Porsino for free; no bank card needed.
  2. In the panel, open “Templates” and choose “پرسشنامه‌ی مشاوره‌ی پوست”.
  3. Change the questions as you like, publish the form and send the link.

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