Acne Questionnaire

Photo of the right side

Photo of the left side

Straight on photo

Photo of your most problematic area

Be as complete as possible, especially about the products that you are using. We need to know if there are comedogenic ingredients in the products you are currently using that might be clogging your pores and exacerbating your acne.

First Name *

Last Name *

Age *

Gender *
 female male

Ethnicity *

Email *

At what age did your acne start?

Please list any topical or internal medications that you are currently using.

Please list any internal or topical acne medications that you have used. Please explain when and for how long.

Do you have any health conditions or medications that you are taking?

Do you have any skin or food allergies? If yes, please describe.

Check if you are allergic to:
 sulphur aspirin

Have you ever had bad or allergic reaction to anything you have ever put on your face? *
 Yes No

If so, what was the product and what kind of reaction did you experience?

Are you currently pregnant or nursing? *
 Yes No

Are you using birth control? If so, what kind?

Please list all supplements, vitamins, energy bars, protein drinks that you take.

Are you using a daily SPF? If so, what kind?

What else are your skin care concerns except for acne?
 Blackheads Dark Spots Razor Bumps Cysts Pimples/Pustules Bumps or Pebble Under the Skin Milia Shaving Irritation Age Spots Broken Capillaries Dry, Flaky Skin Oily Skin Fine Lines/Wrinkles Dehydrated Skin

What is your general Skin Type? *
 Oily Normal Dry Combination

Is your skin sensitive?
 Yes No

If yes, please explain why you think so:

What brand of shampoo and conditioner are you using (give a full name, please).

Do you use oils on your face, scalp or hair?

Let us know how you would like our acne specialist to contact you:
 FaceTime WhatsApp Regular phone call