* Phone Number
Does your occupation require you to work outdoors?
How did you hear about us?
List all known allergies
List all medications that you are currently taking
List any medical conditions or illnesses that you are aware of
Are you on any special diet requirements or restrictions?
Family Acne History
Select any relatives who have (or had) acne
Family Acne History
What age did your relatives' acne begin? Describe the acne condition.
At what age did your acne begin?
What is the state of your current acne?
At it's worse
At it's best
The same as usual
Have you ever had your acne treated by a physician or dermatologist?
Prior treatments and results
If you answered yes to the above, please let us know if you have tried any of the following products/services and rate your acne on a Worse/Better/No Effect scale.
Vitamin A Product (Retin-A, etc.)
Injections into Cysts
Special Soaps and Scrubs
Do your acne flare ups follow a monthly pattern?
If so, when do these flare-ups occur?
During Period? Point of Cycle or Ovulation? Week Before Period?
Have you taken oral contraceptives?
If so, which brands and for how long? Are you currently taking them? Do they improve your acne?
Are you currently pregnant, planning to become pregnant or lactating/breastfeeding?
If you have ever been pregnant, did pregnancy flare up your acne condition?
Products You Currently Use
Please indicate the skincare products that you are currently using and when. List the specific brands and the times of day that you use them.
Please include cleansers, masks, day moisturizers, night moisturizers, toners, exfoliators, sunscreen, eye products, makeup products (concealers, foundations, bronzers, powders and blush).
Please indicate the body products that you are currently using and when. List the specific brands and the times of day that you use them.
Include shower gel, body lotion, scrub, SPF and self-tanner products. How often do you use them? What brands do you use?
Do you find that your acne is related to stress?
If yes, explain why.
Does your acne seem related to the amount of sleep you get at night?
How many hours of sleep do you get each night?
What time do you go to bed? What time do you wake up?
What is your sleeping position at night?
Do you work around any chemicals, oils, humid or hot conditions?
Do you play sports?
If yes, what sports do you play?
Do you consume dairy?
If yes, please indicate which dairy products you consume and how often.
Do you smoke?
What are your typical working hours?
Do you squeeze, pop, pick or manipulate your pimples? Be honest. We won't judge!
If yes, how often?
Once or twice a week
Once a month
Explain how you pick or touch your acne:
Do you scratch or pop with your fingers? Nails? Open with a needle? Use a tweezer?
When you squeeze do you get any contents out? Or are you able to extract anything?
Do you pick at lesions in front of a mirror?
Do you pick at your acne subconsciously or without realizing it?