ACNE INTAKE FORM

 

Please complete and submit the form below PRIOR TO YOUR FIRST APPOINTMENT. If you are unable to fill out the digital form below, please download and print this form and bring a hard copy along with you. This information will be analyzed and discussed during your first session, so please fill it out as honestly and accurately as possible.

General Questions
Name *
Name
Birthdate *
Birthdate
Address
Address
Phone Number *
Phone Number
Acne History
Select any relatives who have (or had) acne
What age did your relatives' acne begin? Describe the acne condition.
Medical Supervision
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.) Benzoyl Peroxide Oral Antibiotics Topical Antibiotics Special Diets Chemical Peels Injections into Cysts Special Soaps and Scrubs
Female Clients Only
During Period? Point of Cycle or Ovulation? Week Before Period?
Products You Currently Use
Please include cleansers, masks, day moisturizers, night moisturizers, toners, exfoliators, sunscreen, eye products, makeup products (concealers, foundations, bronzers, powders and blush).
Include shower gel, body lotion, scrub, SPF and self-tanner products. How often do you use them? What brands do you use?
Other Factors
If yes, explain why.
Select any of the following items that regularly touch your face, back or affected acne areas:
Picking Habits
Do you scratch or pop with your fingers? Nails? Open with a needle? Use a tweezer?