Acne Bootcamp Intake Form
Name
First Name
Last Name
Date of birth
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date
-
Month
-
Day
Year
Date
I give permission to The Tailored Aesthetic to use photographs taken for social media, advertising or promotion.
*
Yes
Only for chart purposes
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Medications
Rows
When
How Long
Antibiotics
Accutane
Benzoyl Peroxide
Retin A
Cream or Gel
Tazorac
Differn
Azelex
Cleocin-T
E-mycin-T
Copaxone
Corticosteroids
Quinine
Other Meds
Medical History (Check all that apply)
Rows
Check if applies
Herpes Simplex
Ecezma
Psoriasis
Hepatitis
Cancer
Staph/MRSA
HIV/AIDS
Thyroid Problems
Hormone Problems
Husterectomy
Ovary (ies) removed
Pacemaker
Hemophilia
Lupus
Anemia
High Blood Pressure
Diabetes
Metal Pins in Body
Your Primary Care Physician & Contact Number
Are you under the care of a Dermatologist? If yes, please list the doctors name
LIFESTYLE CONSIDERATIONS
Have you ever had any reaction to any products or anything you have put on your face? If yes, what products?
Please select any of the following that you are allergic to:
Sulfur
Aspirin
Latex
List any other allergies you know of:
Do you smoke?
Yes
No
Do you use fabric softener or dryer sheets in the dryer?
Yes
No
Do you swim in a chlorinated pool?
Yes
No
Do you work around chemicals, tars, oils, grease or inks?
Yes
No
Occupation & do you work nights?
Are you currently under a lot of stress? (common stress = job loss, new job, wedding, romantic breakup, death in the family or close friend, graduation, difficult home life, long commute, heavily scheduled)
Yes
No
WOMEN: Do you use birth control pills, shots or use an IUD? If so, which do you use? What brand of pill? Are you pregnant or nursing?
Men: Do you have shaving irritation? What type of razor do you use for shaving?
DIET-Do you consume the following?
Rows
Yes
How often per week?
Fast Food
Salty Snacks
Processed Foods
Milk/Yogurt
Cheese
Whey/Soy Protein
Peanut Butter
Peanuts
Sushi
Kelp/Seaweed
Miso Soup
Soy
Vitamins
Seafood
Products Currently Using- Please Provide Product Names
Rows
Please list the product names below
Cleanser
Toner
Serums
Moisturizer
SPF
Mask
Foundation
Blush
Exfoliants(acids, serums, scrubs)
Acne Medication
Anything else?
Other Treatments: What else have you done for your skin in the last 90 days?
Rows
When
Where
Chemical Peels
If so, what kind:
Microdermabrasion
Dermabrasion
Laser Hair Reduction
Laser Resurfacing
Skin Cancer Removal
Facial Waxing
Electrolysis
Other:
Submit
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