Acne Bootcamp Intake Form

Acne Bootcamp Intake Form
Name

First NameLast Name
Date of birth
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date

MonthDayYear
Date
I give permission to The Tailored Aesthetic to use photographs taken for social media, advertising or promotion.*

YesOnly for chart purposes

Medications

Medical History (Check all that apply)

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:

SulfurAspirinLatex
List any other allergies you know of:
Do you smoke?

YesNo
Do you use fabric softener or dryer sheets in the dryer?

YesNo
Do you swim in a chlorinated pool?

YesNo
Do you work around chemicals, tars, oils, grease or inks?

YesNo
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)

YesNo
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?

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?

LIFESTYLE CONSIDERATIONS